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SYPHILIS OF THE INNOCENT 



A Study of the Social Effects of 
Syphilis on the Family and the Community 

With 152 Illustrative Cases 



Made under a Grant from the 
United States Interdepartmental Social Hygiene Board 



HARRY C. SOLOMON, B.S., M.D. 
n 

Chief of Therapeutic Research, Boston, Psychopathic Hospital 

Instmotor in Psychiatry and Neuropathology, Harvard Medical School 

AND 

MAIDA HERMAN SOLOMON, A.B., B.S. 

Besearch Social Worker, 
Boston Psychopathic Hospital, Boston 



WASHINGTON 

UNITED STATES INTERDEPARTMENTAL 

SOCIAL HYGIENE BOARD 

1922 



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Copyright, 1922, by 
Haery C. Solomon 



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PREFACE 



For some years we have been interested in the family of the 
syphilitic. This interest has extended beyond the purely 
medical problems to the social effects of syphilis. There has 
come the realization that in many instances syphilis is a 
c; disease which invades the family. The family being but a 
i unit of the community, it follows that the communal structure 

is also involved. The United States Interdepartmental Social 
Hygiene Board has granted us funds for the study and in- 
vestigation of problems related to the familial and social 
aspects of syphilis. The results of several studies have been 
published in current journals, but as our investigations 
increased it seemed to be more satisfactory to publish them 
as a unit rather than as separate entities. We have attempted 
to present the subject of syphilis in its social aspects, por- 
traying the practical problems as they actually arise in the 
handling of syphilitic cases, and illustrating the text with 
cases from the clinic. It is our hope that we have been able 
to show that the problems of syphilis are many more than 
those of purely medical interest. 

Acknowledgment must be made first of all to the United 
States Interdepartmental Social Hygiene Board whose grant 
of funds made it possible to carry on many of the investiga- 
tions and to collect and publish the material here presented. 
Our revered former chief, Dr. E. E. Southard, suggested the 
idea of presenting our work in the form of a monograph. 
While his untimely death prevented him from giving the over- 
sight and advice that he otherwise would have done, we hope 
that we have profited to some extent by what he did give us. 

While the major portion of the material comes from our 
clinic at the Boston Psychopathic Hospital, we have fortu- 
nately been able to collect material from several other sources. 
We would especially acknowledge our indebtedness to the 
following persons and institutions : 

Dr. C. Morton Smith, physician in chief of the South Medical 
Department of the Massachusetts General Hospital, Boston, 



IV PREFACE 



and Miss Ora M. Lewis, chief social worker of the Depart- 
ment; the Children's Hospital, Boston, for the privilege of 
using cases from their clinics ; Dr. W. A. Hinton of the Wasser- 
mami Laboratory of the Massachusetts Department of Public 
Health who, through his cooperation over a period of years, 
has enabled us to examine and follow our cases serologically 
in a manner that is rarely possible, and who gave us access 
to original statistics concerning the "Wassermann reaction on 
various groups of patients ; our present chief, Dr. C. Macfie 
Campbell, who has been most helpful in reading the manu- 
script and offering valuable suggestions, in addition to having 
done everything possible to facilitate our work from the 
material side; Dr. H. A. Bunker, who has been kind enough 
to give a very careful reading of the proof. 

The work has been greatly lightened by the conscientious 
and intelligent secretarial assistance of Miss Louise C. Francis 
and Miss Theresa Vesce. Finally, we acknowledge our in- 
debtedness for editorial assistance and care of publication 
details to the American Social Hygiene Association and 
especially to Mr. Kenneth M. Gould. 

H. C. S. 
M. H. S. 

Boston Psychopathic Hospital. 



CONTENTS 



Preface. 



m 



CHAPTER I 



The Individual 



The Mate 


CHAPTER II 


The Child 


CHAPTER III 


The Family 


CHAPTER IV 


The Community . . . 


CHAPTER V 



14 



36 



112 



187 



Index 



234 



CHAPTER I 
THE INDIVIDUAL 

Syphilis as a Disease. — Syphilis is a chronic, infectious, 
contagious disease, caused by a specific organism known as 
the Treponema pallidum, or the Spirochaeta pallida. It is a 
disease, which, unless cured, runs a course as long as the life 
of the person infected. It is characterized by exacerbations 
of symptoms and by long periods in which there is no evidence 
of disease so far as the subjective feelings of the patient are 
concerned. It has a tendency, nevertheless, to cause various 
types of physical and mental deterioration, and may lead to 
incapacity or death. 

Syphilis has a very much broader significance than attaches 
to mere consideration of the individual who originally acquired 
the disease. Every syphilitic person must be considered as 
a focus of infection, as a potential danger to the community, 
in the same category with the ' ' typhoid carrier. " He is thus 
liable to certain rules and regulations for the benefit of the 
public health. In addition, as the disease may lead to dis- 
integration of the person's mental and physical abilities, the 
infected individual must be viewed as a possible social lia- 
bility. He is likely to become incapable of caring for his 
family, to be the progenitor of defective children, or to 
become an inmate of a public institution. 

Methods of Infection; Incubation and Primary Periods. — 

It will probably be most satisfactory to sketch the life his- 
tory of syphilis by considering it in relation to an individual. 
Infection with syphilis means that the Treponema pallidum, 
the organism of the disease, has in some manner made its way 
through the skin or mucous membrane of the body, and thus 
gained access to the underlying tissues. As a rule this occurs 
through contact between person and person. It is possible, 
although less usual, for this contact to occur through the 
mediation of an object which has been contaminated by 
treponemata from the body of an infected individual. These 



A SYPHILIS OF THE INNOCENT 

treponemata may then be carried over to the body of a second 
person. Sexual intercourse is the most frequent method by 
which the disease is spread, but there are many instances of 
extragenital infection. For some little time there is no indi- 
cation that anything has happened. Then at the end of from 
three to six weeks there occurs what is known as a chancre, 
or primary sore. The period from the moment that the 
treponemata enter the body until the appearance of this sore 
is known as the incubation period. During the incubation 
period the treponemata which have entered the body begin 
to multiply. They make their way through the lymphatic 
vessels which drain the locus at which they entered and reach 
the blood stream by which they are carried throughout the 
body. Thus, during this incubation period, although the 
patient knows of nothing untoward, his body is being invaded 
by numerous organisms. Finally, after several weeks, the 
local reaction appears, and with its development the so-called 
primary period of the disease begins. This local reaction 
characteristically takes the form of a painless papule, which 
slowly increases in size, reaching, ordinarily, the dimensions 
of a small pea. It is prone to assume a crater-like shape, and 
with the suiTOunding tissue to become indurated. Unless it is 
then secondarily infected by some pus-producing organism, 
there is no purulent exudate, but only a thin serous excretion. 
The glands which drain this region shortly become enlarged 
and fairly hard. It is rare, indeed, that they become sec- 
ondarily infected. Thus, if the sore is on the genitals, the 
glands in the groin will become easily palpable and have a 
shot-like hardness. If the chancre is on the lip, the glands 
under the chin will become swollen. 

Diagnosis of Primary Stage by Inspection. — The primary 
sore is rarely painful or in itself a serious symptom. Occa- 
sionally it becomes infected and leads to grave and unpleasant 
consequences. Such infected chancres are spoken of as 
phagedenic, and a considerable amount of local damage may 
be done. Ordinarily the chancre will begin to disappear, 
with or without treatment, after the third or fourth week. 
It slowly recedes in size, and soon becomes only a scar. If 



THE INDIVIDUAL 6 

the lesion takes on its most characteristic appearance and is 
located on the genital organs it will readily be recognized by 
a physician. When, however, it is located on the finger, lip, 
or tonsil, it is much less likely to be recognized by its physical 
characteristics. When it occurs inside of the vagina, on 
the uterus, or in the urinary meatus it may be entirely over- 
looked. Many times the chancre does not present character- 
istic features, but may be merely a small excoriation. It not 
infrequently occurs at the same time with gonorrhea or with 
what is known as a soft chancre, non-syphilitic in nature. 
Under these circumstances, diagnosis is not easy by mere 
observation. 

Laboratory Aids to Diagnosis; Demonstration of Organ- 
ism. — Fortunately, however, there is a more exact method of 
making the diagnosis than by depending merely upon the 
physical picture. The most satisfactory method of diagnosis 
at the early period of the primary stage is by the demonstra- 
tion of the organism of the disease. This organism is quite 
characteristic in its appearance. It can best be demonstrated 
by the dark-field microscope. A drop of the secretion 
examined in this way by a person expert in the procedure, 
will practically always demonstrate the treponema in the first 
weeks of the disease. Every modern clinic dealing with 
syphilis has facilities for such an examination, and both pri- 
vate and public laboratories are available to the physician 
who is without the proper equipment. 

Wassermann Reaction and Diagnosis. — During the first 
week or two after the appearance of the primary sore, the 
Wassermann reaction is negative and thus, at this period, is 
of no help in making a diagnosis. After the second or third 
week, and certainly by the fourth or fifth week, the Wasser- 
mann reaction becomes positive, and affords another very 
satisfactory and reliable method of diagnosing the disease. 
It is very important, however, to make a diagnosis before the 
Wassermann reaction becomes positive, because the earlier 
the diagnosis is made and treatment instituted, the more 
satisfactory will be the results of treatment. 



4 SYPHILIS OF THE INNOCENT 

History and Diagnosis. — Later in the primary stage the 
diagnosis of syphilis is made not only from the Wassermann 
reaction but from the history, which includes the evidence of 
exposure and an incubation period of several weeks, followed 
by the chancre and the enlargement of the regional lymph 
glands. 

Apparent Innocuousness of Primary Period. — Since the dis- 
covery of the treponema in 1906 and the Wassermann reac- 
tion in 1909, syphilology has entered into a new era. Many 
more cases are being correctly diagnosed in the primary 
stage, owing to the possibility of establishing the diagnosis 
practically as soon as the first objective evidence of a lesion 
appears, as well as during the first weeks of the disease. 
Previously to 1906 it was often necessary to withhold diag- 
nosis and delay treatment for some time, in order to watch 
the course of the disease and see whether the manifestations 
of the secondary stage would confirm the suspicions of a 
syphilitic diagnosis. This was really necessary, for one can 
readily understand what a terrible injustice to the patient it 
would be to make an erroneous diagnosis of syphilis with its 
concomitant implications and mental suffering. By our 
ability to make an early diagnosis one battle has been won 
against the vagaries of the syphilitic manifestations. One 
of the ways the disease is still able to get the better of us is due 
to its apparent innocuousness in this early stage. The chancre 
may be quite painless and the general condition of the patient 
seem in no way affected. However, even before the appear- 
ance of the chancre the disease has become systemic and the 
entire body invaded by the treponema. For this reason, 
localized treatment has relatively little value in curing the 
general infection. Indeed it has a great disadvantage if 
applied before the diagnosis is thoroughly confirmed, as the 
action of mercury on the lesion tends to kill the superficial 
treponemata, making the demonstration of the organisms 
very difficult. 

Contagiousness of Primary Period; Importance of Early 
Treatment.— During the first stage the patient is extremely 



THE INDIVIDUAL 

contagious to others. This contagiousness certainly occurs 
with the first appearance of the primary sore, and there is a 
chance that it may be present even earlier. As a rule, several 
days elapse before the patient seeks advice. During this 
period he may infect others. As every syphilitic in the 
primary stage is a most dangerous focus of infection, unless 
treatment is instituted at once to sterilize the individual, he 
will continue to be "a carrier' ' for a long time. Treatment 
at this early period is of the utmost importance for the rea- 
sons, first, that it protects others in the community against 
the infection; second, because the most good can be done to 
the individual; and third, because with proper care at this 
time, the patient may avoid becoming a social liability years 
later. Thus, for its own protection, society has a vital in- 
terest in seeing that the patient receives an early diagnosis 
and adequate treatment. The care and treatment of syphilis 
is at least as important to the public as the proper control of 
smallpox, typhoid fever, or other infections, and it is more 
prevalent than most of the other infections. 

Amount of Treatment for Sterilization of Contagiousness; 
Hospitalization. — Arsphenamin (salvarsan) has the utmost 
value in the sterilization of the disease, that is, in producing 
a noncontagious condition. In the majority of cases, three 
to five injections of this drug will go a long way toward 
making the patient noncontagious; at any rate, it will cut 
down the infectivity to such a degree that he is no longer a 
danger to anyone except those in the very closest contact. 
The patient must still use great care, of course, to prevent the 
spread of his disease, and this can best be accomplished by 
keeping himself and the implements with which he comes in 
contact away from others. The most satisfactory method of 
handling the early syphilitic in order to protect others is to 
hospitalize him at once. Ideally, he should be placed in a 
hospital as soon as the diagnosis is made. Here he is taught 
cleanliness and care. In addition, he is immediately placed 
under vigorous anti syphilitic treatment, consisting of 
arsphenamin and mercury. At the end of ten days or two 
weeks, in which period he has received three or more injec- 



6 SYPHILIS OF THE IXNOCENT 

tions of arsphenamin and a certain amount of mercury, he is 
relatively sterile as far as the spread of the disease is con- 
cerned. At any rate, he is no longer the dangerous indi- 
vidual that he was. By remaining in the hospital he avoids 
chance contact. He is given more vigorous treatment than 
would be possible if he were about his ordinary business, and 
he is taught the principles of personal hygiene. He can then 
go out into the community with relative safety to others, and 
continue his treatment. 

Early Treatment and a "Cure." — The cure of syphilis is 
never a rapid process. There are many who maintain that 
syphilis is incurable. However, there is much evidence indi- 
cating the probability that cures can be accomplished, or 
that, at least, the patient can remain free from symptoms and 
not endanger others. The earlier treatment is instituted, 
the better the outlook. In cases that receive adequate treat- 
ment beginning at a time before the Wassermann is positive, 
it is frequently possible to prevent this reaction from ever 
becoming positive. While this does not prove that the disease 
has been aborted, it does suggest that a long step has been 
taken in this direction. Some of the German authorities have 
stated that if treatment is started during the early primary 
period, a cure can be obtained by some six months of treat- 
ment. Most American authorities would insist upon a longer 
period of treatment, irrespective of signs or symptoms. How- 
ever, the outlook is relatively very favorable if treatment is 
begun in the early stage and pushed with vigor. Hence, there 
is every reason from the point of view of the patient, his 
progeny, and society to further early diagnosis and treatment. 

Treatment has a tendency to shorten the period of the 
chancre, that is, the chancre will disappear fairly rapidly 
under arsphenamin and mercury, and where the treatment 
has been pushed during the early period the symptoms of the 
so-called secondary period may be prevented. In the un- 
treated case, the primary period lasts, on the average, from 
three to six weeks. 

Secondary Period — Characteristics. — It must be borne in 
mind that there is no sharp line demarcating primary, 



THE INDIVIDUAL I 

secondary, or tertiary periods, but that these divisions are 
made on a symptomatic basis as an aid in the discussion of 
the disease. The secondary period may be said to begin with 
the disappearance of the chancre or the appearance of certain 
other symptoms which are spoken of as characteristic of the 
secondary period. In the typical case, about the time that the 
chancre retrogresses, a rash presents itself on the trunk. This 
rash may be of the most varied type, from a slight blushing 
of the skin to severe skin lesions. One of the most frequent 
forms is the so-called roseola, beginning as a faint reddening 
and then appearing as small red blotches, which fade upon 
pressure of the finger. Occurring at the same time are many 
manifestations of the general invasion. The patient will fre- 
quently feel below par, have aching joints and muscles. 
Slight fever may occur. Headaches of considerable severity, 
frequently much worse at night, are common. Sore throats 
frequently lead the patient to seek medical advice. Falling 
out of the hair and eyebrows (alopecia) are characteristic 
symptoms. 

The symptoms of the secondary stage may be of many 
different varieties, in some cases quite severe, in other cases 
so insignificant as to be unnoticed by the patient. The note- 
worthy feature of this period is the appearance for the first 
time of symptoms due to a generalized infection throughout 
the body. The virus, having circulated throughout the body 
during the primary period, now begins to cause a reaction, 
giving rise to symptoms, these symptoms being merely the 
indicators of a bodily reaction to the disease. They have a 
very real value to the patient in that they lead to treatment. 
Those cases in which the secondary symptoms are not at all 
marked or pass unnoticed, are likely to go untreated. Among 
the severe symptoms which may arise during the secondary 
period are marked skin and mucous membrane lesions. 
These rarely lead to any real damage except a certain scar- 
ring which may be unpleasant esthetically or cosmetically. 
However, the central nervous system itself may be definitely 
involved, and an occasional thrombus (plugging of a blood 
vessel) in the cerebral vessels may produce paralysis. Men- 
ingitis may also occur, leading to severe symptoms or even 



8 SYPHILIS OF THE INNOCENT 

death. The blood vessels are very frequently involved, and 
although the involvement may not be of sufficient degree to 
produce symptoms, it is the forerunner of future trouble. 
The secondary period of the disease may be looked upon as 
a period in which the foundation of later serious bodily 
disease is laid. Involvement of the eyes and ears is another 
not infrequent occurrence. Iritis, hemorrhagic retinitis, and 
opacity of the vitreus may lead to blindness. Involvement 
of the auditory nerve may lead to deafness. 

Clinical and Laboratory Diagnosis in Secondary Period. — 

There are many features of the secondary period, particularly 
in its early stage, which point to the diagnosis of the disease 
from the clinical appearance. The rash, when at all typical, 
as it is in a large number of cases, offers a very satisfactory 
opportunity for diagnosis. The combination of the roseola 
with headache, malaise, falling of the hair and eyebrows, 
patches on the mucous membranes of the mouth, sore throat, 
and condylomata, or skin lesions around the anus or vagina, 
following a few weeks after the appearance of a primary 
lesion, are very definite proof of a syphilitic infection. When 
these symptoms occur, there can be little doubt about the 
correctness of the diagnosis without laboratory assistance. 
The laboratory findings are naturally of very great im- 
portance in conclusively checking up the evidence. During 
the secondary period of the disease, the Wassermann reaction 
is positive in about 100 per cent of the cases. Treponemata 
may be demonstrated from the mucous patches of the mouth 
and from the condylomata. The latter are particularly rich 
in treponemata. A caution may be given in regard to the 
demonstration of treponemata in the mouth : in normal health 
the mouth is frequently the abode of certain varieties of 
treponemata which are not associated with syphilis. It is 
the Treponema pallidum that is the organism of syphilis, and 
it takes a certain amount of knowledge to be able to dis- 
tinguish this treponema from other organisms of related 
groups. 

Contagiousness of Secondary Period; Importance of Treat- 
ment. — The secondary period, like the primary, is a period 



THE INDIVIDUAL V 

of great contagiousness. Every patient in the secondary 
period of the disease may be considered a focus of infection 
and a definite carrier of a contagious disease. It becomes 
obvious that, if treponemata are readily demonstrable in the 
lesions of the mouth, considerable care must be taken in order 
that these organisms may not be spread to other persons. 
Kissing is likely to lead to infection in those cases in which 
there are active mucous membrane lesions, and it is from 
this source that many lip chancres are produced. Care of 
utensils which come in contact with syphilitic patients in the 
secondary period is essential. A comparatively small amount 
of treatment in this period will make the patient relatively 
harmless, certainly as far as ordinary social contact is 
concerned. This is not so true where intimate relations 
obtain. It should be strongly emphasized that there is a vast 
difference between sterilization in the sense of the ordinary 
relations of business and social contact and that required for 
the intimacies of family life. It should also be borne in mind 
that there is a similar difference between sterilization as far 
as the likelihood of infecting the casual contact is concerned, 
and a cure of the disease. It is likewise true that while a 
small amount of treatment gives this relative sterility it will 
not last over a long period of time if treatment is discon- 
tinued. It is essential that the treatment be continued faith- 
fully for months or years, in order to produce a complete non- 
contagiousness. Treatment in the secondary period is very 
important from the standpoint of the patient's prognosis, as 
well as of his contagiousness to others. The ideal time to 
begin treatment, of course, is the very earliest period after 
the organism has reached the body. If this is not accom- 
plished during the primary stage, then the earlier in the 
secondary stage treatment is begun, the better the prognosis 
of the patient. 

One frequently sees the patient for the first time in the 
secondary period of the disease, when the rash or sore throat, 
mucous patches, malaise, and the like, lead him to consult a 
physician. This is especially true in the case of women, in 
whom the chancre may be intravaginal or uterine, and hence 



10 SYPHILIS OF THE INNOCENT 

not detectable. The same is true of the majority of oases 
of extragenital infections. 

Tertiary Period; Possibility of Involvement of Many 
Organs of Body. — There is no definite demarcation between 
the secondary and tertiary periods of syphilis, and, as has 
already been mentioned, these terms are chiefly applicable 
for purposes of description. The differentiation of secondary 
and tertiary periods has been based largely upon the time of 
the appearance of skin lesions rather than upon any other 
characteristic of the disease. As one comes to regard syphilis 
more and more as a generalized infection and less as a skin 
disease, the arbitrary distinction between secondary and ter- 
tiary periods breaks down, and it is more logical to consider 
the early and late manifestations of the disease. However, 
it may be stated in a general way that the symptoms which 
have been described as occurring frequently in the secondary 
period tend to change their form or to disappear, somewhere 
around one to two years after the primary infection. The 
roseola and alopecia are likely to improve spontaneously, 
even if untreated, at the end of six months or thereabouts. 
Sometime during the second year of the disease lesions of a 
somewhat different type begin to make their appearance and 
hence about this time the disease is considered as having 
passed into the tertiary period. 

As has been stated, the disease is always a generalized one, 
involving the various parts of the body. The treponemata, 
circulating as they do throughout the blood stream, may reach 
any portion of the body. During the early period the blood 
contains a great number of circulating organisms. As a re- 
sult of the defense reactions of the patient a large proportion 
of them are killed. A residual number, however, remain im- 
planted in the various organs of the body and it is from the 
activity of these organisms that the later manifestations are 
likely to result. One rather definite characteristic of the 
treponema is a tendency to involve the blood vessels, and it 
is chiefly through disease of the blood vessels that the later 
troubles become manifest. It is also true that the organisms 



THE INDIVIDUAL 11 

may make a habitat in any organ, where they remain 
apparently dormant for years, only to come later into definite 
activity. It may, therefore, be said that any organ or por- 
tion of the body may show late signs of syphilitic disease. 
The skin, the bones, the internal organs, — lungs, liver, kid- 
neys, — the vascular system, blood vessels and heart, — the cen- 
tral nervous system — all may become affected by the trepo- 
nemal toxins. As a result, syphilis may simulate almost any 
form of disease. Its late manifestations lie in the province of 
all specialists of medicine, the internist, the neurologist, the 
psychiatrist, the dermatologist, the aurist, the ophthal- 
mologist; in fact, there is no specialty which is not concerned 
with its problems. 

Apparent Latency of Disease. — One of the important char- 
acteristics of syphilis is the apparent latency or inactivity for 
years or decades. It is frequently the case that the patient, 
after his primary or secondary symptoms, or even when these 
have not been noted, has remained in what he considers the 
best of health, without any manifestation of illness related to 
syphilis, for a period of many years, ten, fifteen, twenty, 
thirty, or even forty years, and then has become the victim of 
a severe disorder caused entirely by syphilis. This period of 
so-called latency may, therefore, be considered apparent rather 
than real. Probably for a time the treponemata are relatively 
inactive, and then gradually becoming more and more active, 
lead to a destruction of tissue. This destruction of tissue 
may be very slow and be unaccompanied by symptoms until 
the damage is marked and severe. As an illustration, damage 
to the blood vessels may progress slowly for a period of years 
without the patient's being aware of the fact. The process 
continues progressively until some day the patient finds him- 
self less capable of activity, short of breath, possibly with pain 
in the chest, and examination may then disclose a large 
aneurysm. This condition, a destruction of the aorta, is one 
which can hardly be improved by medical treatment, 
or at least, only very slightly. During all this period the 
patient is likely to consider himself cured or the disease in- 
active, whereas, on the contrary, it has been most active and 
wrought the utmost damage. 



12 SYPHILIS OF THE INNOCENT 

A similar story holds for the central nervous system, where 
the organism may be actively destroying the tissue for years 
before the symptoms arise which lead to its recognition. By 
the time such symptoms are noticed a great deal of destruc- 
tion, irreparable in type, may have occurred. Such is the 
history of many cases of tabes dorsalis (locomotor ataxia) 
and general paresis of the insane. From the point of view of 
frequency and the severity of the damage done, syphilitic 
involvement of the cardiovascular system and that of the ner- 
vous system are the most important. All the other systems, 
as already stated, are liable to involvement and are frequently 
affected. In some instances, such as bone and skin lesions, 
the damage may be relatively less important because it does 
not affect life and usefulness to the same extent, and the 
lesions are much more satisfactorily treated. 

Clinical Diagnosis of Tertiary Period; Therapeutic Test. — 

The diagnosis of late syphilis is often very difficult and ob- 
scure. Certain syndromes are recognized as usually, if not 
always syphilitic, and thus from the clinical picture a diag- 
nosis may be made. Thus arteriosclerosis and angina pectoris, 
occurring in young people, are most often due to syphilis. 
In the majority of instances aortic aneurysms are considered 
as syphilitic. Tabes dorsalis and general paresis are always 
syphilitic diseases. Skin lesions are likely to be fairly 
characteristic, so that the diagnosis can be made upon their 
appearance. Often the conclusion that the patient has had 
syphilis is arrived at on the basis of his past history or of 
the finding of certain characteristic skin and mucous mem- 
brane lesions. Considerable clinical acumen is essential. In 
certain conditions such as ulcers, enlarged liver, etc., diag- 
nosis is completed by the so-called therapeutic test. If anti- 
syphilitic treatment leads to rapid improvement, it may be 
assumed that the condition was of syphilitic origin. The 
therapeutic test is valuable in certain cases. But it has the 
disadvantage of often wasting time before one can be sure. 
This is particularly unfortunate in cases which are not 
syphilitic. It also is of little value in those cases in which 
antisyphilitic remedies will not produce very rapid or 
satisfactory results. 



THE INDIVIDUAL 13 

Laboratory Aids to Diagnosis in Tertiary Period; Wasser- 
mann Test. 1 — The Wassermann test is of great value, though 
by no means a final criterion. Although a great number of 
late syphilitics have a positive Wassermann reaction, there 
are late syphilitics with active lesions who do not give a posi- 
tive reaction. On the other hand, it does not follow that be- 
cause the patient has syphilis the symptoms from which he 
is suffering are of syphilitic origin. A positive Wassermann 
may show the presence of a latent syphilitic process in a 
patient with symptoms of another disease. 

Spinal Fluid Examination; Luetin Test.— In cases of 
syphilis of the central nervous system the spinal fluid examina- 
tion is of great importance. In the overwhelming majority 
of these cases positive findings leading to the diagnosis will 
be present. There are several tests in addition to the Wasser- 
mann reaction which are positive in the spinal fluid in the 
cases of central nervous system disease. Noguchi's luetin 
test is another satisfactory test for syphilis. Unfortunately, 
few people are in a position to read correctly this skin reaction 
for syphilis. 

It will be seen that the last fifteen years have given methods 
that enable a diagnosis of syphilis to be made with a high 
degree of accuracy. This is especially true of the primary 
and early secondary periods and of a large percentage of 
cases with central nervous system involvement. In the cases 
that are missed the responsibility for the omission must rest 
with either the patient or the physician. The importance of 
diagnosis transcends the mere interests of the individual. A 
correct diagnosis affects society from the standpoint of a con- 
tagious disease which may be spread, one which attacks the 
present or future mates and children of the infected indi- 
vidual and. which in addition causes loss of service and 
efficiency. Treatment can do much to reduce the dangers, 
and the earlier the treatment is introduced the greater the 
chance of its efficacy. Thus, we must envisage syphilis in 
the individual as a matter of the greatest interest and 
importance to society. 

l Somewhat similar or more ample discussions of the Wassermann reaction 
will be found in chap. 2, p. 32, chap. 3, pp. 50, 74, 104, chap. 4, pp. 141-144, 173, 
176. 



CHAPTEE II 

THE MATE 

Syphilis Acquired Innocently. — It has been shown that 
syphilis is a contagious, infections disease. It is fre- 
quently spread through sexual intercourse, and promiscu- 
ous sex relations expose an individual to it. Very often, how- 
ever, it is acquired by individuals who have committed no 
indiscretions and thus one may well speak of syphilis acquired 
innocently. The person who marries and is infected by his 
or her mate must be considered an innocent victim of syphilis. 
The child who is born into the world with the germs of 
syphilis transmitted from the parents is an innocent sufferer. 
The acquisition of syphilis through ordinary social relations 
with an infected person, or from objects contaminated by the 
organism of the disease is still another instance of innocent 
infection. 

Likelihood of Mates' Acquiring Disease. — Syphilis is spread 
in large part by personal contact. Propinquity to a syphilitic 
person exposes one to infection. In modern society husband 
and wife represent the closest relationship. This is true both 
for genital and extragenital contact. When one member of 
a married pair has syphilis, the other member runs a great 
risk of becoming infected. Thus, in dealing with the epidemi- 
ology of syphilis the mate of a syphilitic is always of major 
interest, and because of the close contact it would seem that 
the possibility of infection of the mate of every syphilitic 
person should be seriously considered. The innocently in- 
fected mate may be male or female. In the following pages 
we shall include under the term "innocent," syphilis con- 
tracted by either husband or wife in the marriage state. 

Greater Prevalence Among Men. — Syphilis is more preva- 
lent among men than among women. Without knowing the 
actual number of syphilitic persons in the community one 

14 



THE MATE 15 

cannot give exact figures but only opinion based upon experi- 
ence. The examination of various random groups of men 
and women points to the greater prevalence among men. 

Evidence from Boston Psychopathic Hospital Study of 
General Paretics. — A statistical study was made of 755 con- 
secutive cases of general paresis admitted to the Boston Psy- 
chopathic Hospital between 1912 and 1919. There were 638 
males (84.5 per cent) and 117 females (15.5 per cent). This 
indicates that there are between five and six times as many 
male as female paretics in the hospital population. 

Evidence from New York Study of General Paretics. — These 
figures corroborate the evidence given by Dr. Salmon 1 in 
1914 when he showed that in New York State one in nine of 
the 6909 men and one in thirty of the 5299 women who died 
between 40 and 60 years in 1913 died from recognized general 
paresis. This ratio would indicate that between three and 
four times as many of the deaths in men as in women are 
caused by general paresis. 

Evidence from Admissions to Michigan State Hospitals. — 

Syphilis is the direct cause of 17.5 per cent of the male and 
of 6.65 per cent of the female admissions to Michigan State 
Hospitals. 2 This means chiefly general paresis, cerebrospinal 
syphilis, and tabes, and would indicate that syphilitic mental 
disease is about three times as prevalent in males as in 
females. 

Evidence from Royal Commission on Venereal Diseases 
Study of General Paretics. — The Royal Commission on Vene- 
real Diseases, England, 3 examined the incidence of general 
paresis in the pauper admissions to the asylums for 1908- 

1 Salmon, Thomas W., General Paralysis as a Public Health Problem. Pro- 
ceedings of the American Medico-Psychological Association, Seventieth Annual 
Meeting, Baltimore, Maryland, May 26-29, 1914. 

2 Report of the Commission to Investigate the Extent of Feeble-mindedness, 
Epilepsy, and Insanity and Other Conditions of Mental Defectiveness in Michigan, 
1915, p. 31. 

3 Royal Commission of Venereal Diseases. Final Report of the Commissioners, 
London, 1916, p. 124, Appendix X. 



16 SYPHILIS OF THE INNOCENT 

1912. They found the rate among males to be 3.07 and among 
females .55 per thousand. This is an incidence of between 
five and six times as great for males as for females. 

It is fair to conclude that general paresis is at least four 
times as prevalent among men as among women. One cannot 
then say that syphilis is four times as frequent in men as in 
women, as there are other factors leading to the production of 
psychoses that are different in the two sexes, as childbearing, 
alcoholism, trauma, and the like. However, the figures indi- 
cate a preponderance of syphilis in men. 

Evidence from Wassermann Surveys at Boston Psycho- 
pathic Hospital (Table 1). — Wassermann surveys on the same 
sort of patients bear out this point (Table 1). Of the 1730 
admissions to the Psychopathic Hospital for 1919, 52.5 per 
cent were males and 47.5 per cent females. Of the syphilis 
found, 65.2 per cent was among the males and only 34.8 per 
cent among the females. Stated differently 14.85 per cent of 
the males and 8.77 per cent of the females were syphilitic. 
After allowing for the slight preponderance of males in the 
total group, there is almost twice as much syphilis among 
the men as among the women. 

Greater Prevalence Among Males According to General 
Hospitals (Table 2). — Another method of comparing preva- 
lence is a consideration of the number of male and female 
syphilitics in general hospitals and clinics. The total on 
Table 2 shows a slight preponderance of syphilis among 
males. 



THE MATE 



17 



Table 1. Prevalence of Syphilis among Insane Men and Women 





Male 


Female 


Clinic 


Number 
of 
In- 
dividuals 


Positive 

Wassermann 

Reaction- 


Number 
of 
Lv- 

DIVIDUALS 


Positive 

Wassermann 

Reaction 




No. 


P. C. 


No. 


P. C 


Boston Psychopathic Hospital, Mass. 


1 
908 | 135 


14.85 


822 


72 


8.77 


Michigan State Hospital, Mich. 1 


940 


203 


21.6 


606 


77 


12.7 


Warren State Hospital, Pa. 5 


... 




22.3 






18.5 



1 Vedder, E. B., Syphilis and Public Health, Philadelphia and New York, Lea 
and Febiger, 1918, p. 52, quotes, Influence of Syphilis Upon Insanity and Mar- 
riage. From the Report of the Commission to Investigate the Extent of Feeble- 
mindedness, Epilepsy, and Insanity and Other Conditions of Mental Defective- 
ness in Michigan, 1915. 

2 Darling and Newcomb, A Comparison of the Wassermann Reaction Among 
the Acute and Chronic Insane, Journal of Xervous and Mental Diseases, xli, 
1914, p. 575, quoted by Yedder, p. 50. 



18 



SYPHILIS OF THE IXXOCEXT 



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THE MATE 19 

The larger number of male syphilitica is due in part to the 
double standard of morality and to the more indiscriminate 
sexual relations of men. While one syphilitic man will prob- 
ably not infect a great number of women, the victims of one 
syphilitic prostitute may be legion. If it were not for the 
relatively large number of women who acquire syphilis in 
marriage the proportion of male to female syphilitics would 
be even larger than it is. 

Conjugal Syphilis. — The danger of contagion is directly 
proportional to the infectivity of the disease as it exists in the 
contaminated party. Syphilis may be acquired by an indi- 
vidual prior to or after marriage. In either case the mate is 
exposed to infection. When syphilis is transmitted from 
husband to wife or wife to husband it is called conjugal 
syphilis. We are not able to find the date when conjugal 
syphilis was first recorded, but the early literature on syphilis 
refers to the matter. 

More Frequent among Women; Blaisdell 5 s Study. — As men 
more often acquire syphilis before marriage the mate who 
acquires syphilis in marriage is more often the woman. Thus 
one finds more single than married syphilitic men and more 
married than single syphilitic women. This is shown by 
Blaisdell, 1 who has studied a series of 500 consecutive cases of 
adult syphilis. He reports the civil condition as follows : 236 
single men, 98 married men, 35 single women, 131 married 
women. In the male group there were more than twice as 
many single as married men, while there were practically four 
times as many married as single women. The danger to 
wives as shown by this study is even greater than would 
appear. The syphilitic men were young. Seventy-two per 
cent had contracted syphilis before their thirtieth year. 
Sixty-three per cent had early or secondary syphilis. An 
average of 70 per cent made less than five visits to the clinic 
and hence had insufficient treatment. The danger to the wives 
and children of the married men can be visualized. Many of 

l Blaisdell, J. H., The Menace of Syphilis of To-day to the Family of To- 
morrow, Boston Medical and Surgical Journal, vol. clxxv, no. 1, July 6, 1916, 
pp. 18-19. 



20 



SYPHILIS OF THE INNOCENT 



the unmarried will undoubtedly marry uncured and infect 
their wives. 

Case 1} George Swallow acquired syphilis one year before his 
marriage. He had a small amount of treatment, insufficient to pro- 
tect his wife, who acquired syphilis from him. 

It must always be remembered that not every case of 
syphilis in a married woman means an innocent infection. 

Case 2. Norma Blaine acquired syphilis when about 17 years of 
age. Before her marriage she was sexually immoral and had had a 
miscarriage. At 35 she developed general paresis. Her husband to 
whom she had been married eleven years showed no clinical or labora- 
tory evidence of syphilis. 

Further Statistics on Syphilis in Women (Tables 3, 4, 5). — 

The accompanying tables (3, 4, and 5) give further statistics 
on how many women with syphilis are married or single, how 
many married women acquire the disease from their husbands, 
or otherwise. 



Table 3. Comparative Statistics of Syphilis in Married and 

Single Women 



Clinic 


Total 
Syph- 
ilitic 
Fe- 
males 


Single 


Married 


Married, 

Acquiring 

Syphilis 

from 
Husband 


No History 

of Source 

of Infection 




No. 


No. 


P. C. 


No. 


P. C. 


No. 


P. C. 


No. 


P. C. 


Fournier Cases, Paris 1 


842 


366 

(2 


43.5 

56 status 


220 

unknot 


26.1 
n)- 


164 


74.5 






Bulkley Cases, New 
York* 


131 


23 


17.6 


10S 


82.4 


54 


50.0 






Blaisdell Cases, Boston 
Dispensary, Boston* 


166 


35 


21.0 


131 


79.0 










Psychopathic Hospital, 
Boston 


102 


24 


23.8 


78 


76.2 


18 

5 

(prob 


23.1 
6.47 
ably) 


35 


44.8 



i Fournier. A., Treatment and Prophylaxis of Syphilis, English translation, 
New York, Rebman & Co., pp. 348-351. 

2 Bulkley, L. D., Syphilis in the Innocent, New York, Bailey & Fairchild, 
1898, p. 28. 

3 Blaisdell, J. H.. The Menace of Syphilis of To-day to the Family of To- 
morrow, p. 19. 



i The names assigned to the cases are fictitious and chosen to suggest race or 
descent. 



THE MATE 



21 



Table 4. Further Analysis of Psychopathic Hospital Cases as 
to Sources of Syphilis among Married Women 



Syphilitic Females 


Acquired 
Innocently 


Possibly 

Acquired 

Innocently 


Acquired 

througb 

Immorality 


Probably 

Acquired 

through 

Immorality 


No Definite 

History, 

Apparently 

Moral 


No. 


P. C 


No. 


P. C. 


No. 


P. C 


No. 


P. C 


No. 


P. C. 


No. 


P. C. 


Married 78 


100 


18 


23.1 


5 


6.4 


20 


25.7 






35 


44.8 


Single 24 


100 


1 


4.2 


3 


12.4 


16 


66.7 


4 


16.7 







Table 5. Comparison of Syphilis in the Mate When Original 
Patient is Male or Female 





Mate, Positive 

Wassermann 

Reaction 


Mate, Doubtful 

Wassermanx 

Reaction 


Mate, Negative 

Wassermann 

Reaction 


Total 
Cases 




No. 


P. C. 


No. 


P. C 


No. j P. C. 


No. 


Original Patient, Male 


6 


14.2 


3 


7.1 


33 


78.7 


42 


Original Patient, Female 


21 


50.0 


4 


9.6 


17 


40.4 


42 


Total Mates 


27 


32.1 


7 


8.4 


50 


59.5 


84 



Number of Married Syphilitic Women. — Alfred Founder 
made a careful study of his private cases. He showed that 
of 842 women who derived syphilis from sexual contact 366 
belonged to the demimonde, 256 were of unknown social status, 
and 220 were married; that is, only 26 per cent were defi- 
nitely known to be married. These figures are based upon 
Paris material and hence are probably not valid for the United 
States. Bulkley found in an analysis of the civil status of 
syphilitic women in New York that 82.4 per cent were married, 
while Blaisdell found 79 per cent of his Boston Dispensary 
cases were married. We have found that among 102 syphil- 
itic women at the Psychopathic Hospital in Boston 78 or 76.2 
per cent were married. It would seem fair to assume that in 
the United States about 75 per cent of syphilitic women are 
married. 



Source of Infection in Married Women. — As has been stated 
above, it does not follow that because a woman who has 
syphilis is married that she was infected by her husband. 
Founder's analysis shows that 74.5 per cent of his syphilitic 



22 SYPHILIS OF THE INNOCENT 

married women acquired the disease from their husbands, 
Bulkley could show this in 50 per cent of his cases, and we 
found that 23.1 per cent of our cases certainly, and 6.4 per 
cent additional probably, acquired syphilis in marriage, while 
in 44.8 per cent of our cases it was not possible to determine 
this point. 

A further analysis of our 102 cases of syphilis in women 
(78 married, 24 single) showed that 25.7 per cent of the mar- 
ried women were immoral, as contrasted with 66.7 per cent of 
the single women, and that, whereas 23.1 per cent of the mar- 
ried women had acquired the disease innocently (from hus- 
bands or extragenitally) only 4.2 per cent of the single women 
were definitely innocent victims. The 44.8 per cent of the mar- 
ried women about whom we could not definitely determine the 
source of infection were apparently strictly moral and in some 
instances the husband was known to have syphilis. Conse- 
quently, the number of innocent infections among the married 
women must be much greater than the figure given (23.1 per 
cent) would indicate. We may, therefore, conclude that most 
married women with syphilis have contracted it innocently 
and per contra only a minority of the single women can be 
classed as examples of innocent infections. 

High Percentage of Syphilitic Mates of Syphilitic Women. 

—Table 5 gives a comparison of the amount of syphilis in 
the mate considered from the standpoint of whether the orig- 
inal patient was male or female. Of the original group of 78 
syphilitic women, it was possible to examine the husbands of 
42. For purposes of comparison, therefore, a random group 
of 42 syphilitic men whose wives had been examined were 
chosen. It was found that whereas only 14 per cent of the 
wives of these male syphilitics gave evidence of syphilis, 50 
per cent of the husbands of the women syphilitics were syphil- 
itic. This difference in percentage lends weight to the ideas 
that syphilis is more frequently acquired by men outside of 
marriage than by women, and that much female syphilis is 
marital in origin. Assuming that a high percentage of female 
syphilitics have acquired syphilis from their husbands, one 
would expect a large percentage of the husbands of female 



THE MATE 23 

sypliilitics to be syphilitic. In our group this was true of 50 
per cent. On the other hand, assuming that most men acquire 
syphilis a considerable period before marriage, then a rela- 
tively small percentage will infect their wives. We find in 
the group of Table 5 that in this case 14 per cent of the wives 
were syphilitic. Thus it is seen that the figures are in accord 
with our two assumptions. 

Approximate Percentage of Female Syphilis Acquired 
through Marriage. — On the basis of the preceding figures of 
Fournier, Bulkley, and the Psychopathic Hospital, calcula- 
tions were made to determine what percentage of all syphil- 
itic women (married and single) have acquired syphilis 
through marriage. Fournier found that one in every five 
syphilitic women acquired syphilis in marriage. The Psycho- 
pathic figures are identical with Fournier 's, while from Bulk- 
ley 's material it appears that one in every three women with 
syphilis was maritally infected. 

Extramarital Infection Acquired by Men Before and After 
Marriage. — In considering syphilis among wives it is of inter- 
est to know whether the husband acquired syphilis before or 
after marriage. Fournier 1 shows by an examination of 312 
cases that the first is much more frequent. In 218 cases the 
woman was contaminated by a man who acquired syphilis 
before marriage, in 94, after marriage. Stated differently, 
of 100 women contaminated in marriage 70 owe their infection 
to a syphilis acquired by their husbands before marriage, 
as against 30 infected by syphilis acquired by their husbands 
after marriage. 

Undoubtedly more Frenchmen than Americans are unfaith- 
ful to their wives owing to Continental customs. Thus, prob- 
ably 80 to 90 per cent of American husbands who contaminate 
their wives versus the 70 per cent of French husbands acquired 
the infection before marriage. 

Thibierge 2 shows that the war conditions in France, neces- 

1 Fournier, A., La Syphilis des Honnetes Femmes, Bulletin de 1 'Academie 
de medecine (Seances du 2 et du 9 Octobre 1906) pp. 2-3. 

2 Thibierge, G., Syphilis and the Army, London, University of London Press, 
Ltd. 1918, p. 280. 



/ 



24 SYPHILIS OF THE INNOCENT 

sitating the long absence from home, either in the army or in 
the munition works, resulted in a laxity of morals, so that 
there was considerable extramarital intercourse followed by 
an increase in the number of syphilitic infections. When the 
husband returned home on leave or permanently many wives 
were infected. Although the precautions taken by the Amer- 
ican army made the rate of syphilitic infection very low, there 
is evidence 1 to show that many infected soldiers received only 
enough treatment to render them noncontagious for the time 
being and not enough sound advice on how to act when the 
delayed secondaries appeared so that they could receive 
treatment and their families be protected. 

Syphilis and Marriage. — When syphilis is acquired by one 
of a married pair living in the married state, the chance of 
the mate escaping infection is very small. This follows from 
the general rule that the earlier stages of syphilis are the 
most contagious. Vedder 2 quotes M. Dechambre as stating that 
"syphilis is divided among husband and wife like the daily 
bread.' ' 

The question of when a syphilitic can many without danger 
to the mate depends on three things: the age of the infection, 
the amount and sort of treatment, and the kind of lesions 
shown. A certain number of years must elapse before a 
syphilitic can safely marry, and this time factor is interwoven 
with that of the adequacy of his treatment. Fournier 3 found 
that of 142 women infected by their husbands, 37 husbands 
had been syphilitic for a period varying from a few weeks to 
a year, 31 from a year to two years, and 30 from two to three 
years. Hence 98, or two thirds of the total, had had syphilis 
less than three years when they married. As all these men 
infected their wives, the conclusion is that many syphilitics 
marry too soon after infection. There is a good deal of vari- 
ance of opinion among authorities as to the exact time limit 
and just what constitutes good treatment. 

1 Collins, H. G., Syphilis in the Innocent, Journal of the Kansas Medical 
Society, vol. xxi, no. 1, January, 1921, p. 7. 

2 Vedder, op. cit., p. 137, quotes M. Dechambre. 

3 Fournier, La Syphilis des Honnetes Femines, quoted by Vedder, p. 138. 



THE MATE 25 

It must be emphasized that even after having satisfied the 
first two prerequisites to marriage, there is still the third 
point to be considered, namely, the contagiousness of the 
type of lesion any given individual may develop. It may be 
stated that most conjugal syphilis is transmitted by the 
chancre or early secondary lesions. The consideration of a 
syphiliticus right to marriage will be discussed in more detail 
in the chapter called ' ' The Family. ' ' 

Marriage Soon After Infection as Cause of Conjugal 
Syphilis; No Treatment. — The most frequent cause of con- 
jugal syphilis is marriage within the first year or so after a 
person has acquired syphilis. The chances of the mate's 
being infected are especially great in those cases where the 
syphilitic has not had treatment. 

Case 3. Alice Shelley appeared at the hospital in the early sec- 
ondary period of syphilis. A few weeks prior she had had a still- 
born child. She had been married about ten months and a few 
months after her marriage developed a chancre and skin lesions. Her 
husband admitted that he had acquired syphilis a year before his 
marriage and had not been treated. 

Though an early marriage without treatment is prone to 
cause conjugal infection, this is not an inevitable result. It 
is possible, though probably rare, for the mate to escape. 

Case 4. Etta Prince acquired syphilis at eighteen and received no 
treatment. She married after one year and her husband when ex- 
amined three years later was free from syphilis. 

Inadequate Treatment. — Inadequate treatment is often 
taken by a syphilitic before marriage. This has the effect of 
giving false confidence to the patient. Where marriage takes 
place during the early stages, the mate is very likely to be- 
come infected. 

Case 5. John Collins developed a chancre when a young man. He 
received local treatment for ten to fifteen days. This, of course, was 
entirely inadequate either as treatment of his syphilis or to make him 
noncontagious to others. He married a few months after the disap- 
pearance of the primary lesion. As was to be expected, the wife be- 
came infected and gave birth to a syphilitic child. 



/ 



26 SYPHILIS OF THE INNOCENT 

Marriage Long After Infection and Escape of the Mate. — 

As time goes on syphilis becomes less contagious. Thus, after 
several years a patient may no longer be a source of danger 
to others. This is true even when the patient receives no 
treatment. When syphilitics marry five to twenty years after 
the infection, their mates frequently remain entirely free 
from the disease. 

Case 6. Frances Brown contracted syphilis at the age of 18. She 
was engaged at the time, and infected her fiance. Almost immediately 
after, she became infatuated with another young man whom she 
married a week later. She lived with him for six months during 
which time he also contracted syphilis from her, and left her. A few 
months later she had a child which was born in a frightful condition 
and died immediately. 

In a span of four years, this girl had contracted syphilis herself, 
infected both fiance and husband, and had given birth to a dead 
syphilitic child. 

In the fifth year after her infection with syphilis, she bore an 
illegitimate child. She then lived with the father of this child as 
his wife and had five other illegitimate children. 

She appeared at the hospital at the age of 32. She had never been 
treated and showed a positive Wassermann. Her six illegitimate 
children were examined; none of them were syphilitic. There is no 
history of the father of the children having contracted syphilis from 
her, though the two men who had lived with her in the early stages 
of the disease both became syphilitic. 

Importance of Treatment. — Early adequate treatment is of 
great importance from the standpoint of the spread of the 
disease. This is particularly true when arsphenamin is used. 
A few injections of arsphenamin can do a great deal to lessen 
contagiousness. Even though treatment is not sufficient to 
cure the patient, it may suffice to render his condition non- 
contagious to others. A patient who has received active anti- 
syphilitic treatment in the first few weeks of the disorder may 
even marry during the first year and not transmit the disease 
to his mate. This is taking an undue risk, however, and 
should never be advocated. 

For our present purpose it might be stated that when a 
period of five years or more has elapsed since the date of the 



THE MATE 27 

primary stage the danger to the mate is minimal. This danger 
is further decreased by treatment. When treatment has been 
intensive and continued, the period may be lessened at the 
discretion of the doctor. 

Marriage Long After Infection and Infection of Mate. — All 

rules concerning syphilis must be considered as general and 
not necessarily applicable to any particular case. Thus a 
person may be infected by a syphilitic who has acquired 
syphilis many years prior to marriage. The infections occur- 
ring late in the disease are largely dependent on the occur- 
rence of superficial lesions containing treponemata. Such 
lesions may occur in a patient who has had considerable treat- 
ment but not enough to cure the disease, and the patient may 
then infect the mate. 

Case 7. A case is reported from the clinic of Dr. Max Joseph * of 
a man who married eight years after acquiring syphilis. The wife 
was infected. The man, who was in the late stage of the disease, had 
mucous patches which probably explained the infection of the wife. 

Case 8. Finger 2 reports a man who acquired syphilis in 1888. He 
married eight years later having had mercurial treatment in the 
meantime. Four months after the marriage the wife developed a 
chancre. The husband on examination was found to have papular 
syphilides of the glans and prepuce of the penis. 

Variation in Probabilities of Conjugal Infection When Mar- 
riage Occurs 3-5 Years After Infection. — While marriage to a 
syphilitic many years after the disease is acquired, is rela- 
tively safe, and marriage early in the course of the disease is 
highly dangerous, it is not possible to give any definite state- 
ment as to the probability of conjugal infection in marriages 
contracted from three to five years from the date of the initial 
lesion. In this period, neither very late nor very early, the 
disease is transmitted in some cases, while in others, the mate 
escapes. 

lBuba, Die Contagiositatsdauer der Syphilis, Inaugural Dissertation, Leipzig, 
1905, quoted by Vedder, p. 113. 

2 Finger, Wann Diirfen Syphilitische heiraten, Heilkunde, Wien, 1897, vol. i, 
p. 351, quoted by Vedder, p. 113. 



28 SYPHILIS OF THE INNOCENT 

Case 9. George Carpenter was seen at the clinic at the age of 32. 
He acknowledged contracting syphilis when 16 years of age. He had 
treatment at that time for about three months and off and on ever 
since. Four years after the infection he married. The first pregnancy 
resulted in a stillbirth. He had two living children both of whom 
were syphilitic as was his wife. All three were under treatment. 

Case 10. William Baldwin also married four years after he ac- 
quired syphilis. He had had treatment for seven or eight months 
following the appearance of his chancre, but this was chiefly in the 
form of mercury by mouth. This treatment was inefficient as far as 
he was concerned and he developed late symptoms. His wife, how- 
ever, was not infected. 

One must be on guard about viewing all cases of syphilis 
which occur in both husband and wife as instances of conjugal 
syphilis, and attempting to place the blame on one for the 
disease of the other. It is always quite possible for both 
husband and wife to have acquired syphilis outside of 
marriage. 

Case 11. Three months after his marriage, Harry Coffin showed 
symptoms of general paresis. His wife was examined and found to 
be syphilitic. However, she did not have symptoms of early syphilis, 
such as would be expected if she had been infected during the three 
months of her marriage. Furthermore it is quite certain that a 
patient with paresis without superficial lesions is not contagious. On 
the other hand it was not possible for Harry to have acquired his 
syphilis from his wife. It is, therefore, obvious that in this case each 
acquired syphilis independently before marriage. 

Probable Date of Conjugal Infection. — Having seen that 
conjugal infections occur, attention may be turned to the ques- 
tion of how long after marriage the infection is likely to take 
place. Fournier 1 show r s that of 572 syphilitic women, 81 or 
over 14 per cent contracted syphilis from their husbands dur- 
ing the first days of marriage. In 153 cases Fournier gives 
the following dates for contagion: 

The first month after marriage 10 

The second month after marriage 26 

The third month after marriage 20 

i Fournier, A., Syphilis et Mariage, Paris, G. Masson, 1880, quoted by 
Vedder, p. 137. 



THE MATE 29 

The fourth and fifth months after marriage 7 

The sixth month after marriage 1 

During the first months of marriage (without more precision) 53 

Second part of the first year 13 

Second year 9 

Third year 3 

Fourth year. . 3 

Fifth year. .' 2 

Sixth year 2 

Seventh year 2 

Eighth year 1 

Ninth year 1 

Total 153 

Eighty-six per cent of the infections occurred in the first 
year after marriage, the vast majority (90 per cent) of these 
in the first six months. These figures seem to indicate that 
there is about one chance in seven of being infected after the 
first year. 

Keyes 1 studied the records of private patients who married 
without taking any particular precautions although they were 
actively syphilitic. He drew the following conclusions: 

Wife infected first year of disease, chances 12 to 1 
Wife infected second year of disease, chances 5 to 2 
Wife infected third year of disease, chances 1 to 4 
Wife infected fourth year of disease, almost no chance 
Wife infected fifth year of disease, 2 cases 

Cause of Conjugal Contamination. — The reasons persons 
are contaminated in marriage are various. Some syphilitics 
are unaware that they have contracted syphilis. They may 
have a small and unnoticed chancre with no obvious second- 
ary lesions and may marry in all innocence. Others know 
that they -have had the disease but are not cognizant of the 
dangers to the mate. These are the ignorant and uninformed, 
who it is hoped will diminish in number when the various 
modern educational methods have been in vogue for some 
time. Though education will probably not prevent people 
from running the risks of acquiring syphilis it may arouse 

i Pusey, W. A., Syphilis as a Modem Problem, Chicago, American Medical 
Association, 1915, p. 99, quotes Keyes. 



30 SYPHILIS OF THE INNOCENT 

more caution in taking the risk of harming a mate and chil- 
dren. Many syphilitics are conscious of the general possi- 
bilities of infecting their mates but feel confident that they 
can run the risk with impunity. This confidence may be based 
on a superabundance of faith in someone 's judgment, on per- 
mission granted by a doctor who does not know all the facts, 
on an indifferent attitude towards possible future dangers, 
or on pure callousness. This last attitude is fortunately 
rare. As an example one may quote the following paragraph 
from Fournier: 1 

A man came to rue and asked me if he could marry. Recognizing 
his contagions state, I forbade it. Then naturally he married. Three 
months later he came to me repentant, asking my care for his wife 
Avhom lie had infected. "At least," said I, "You will save yourself 
a new unhappiness and do everything you can to avoid having chil- 
dren. ' ' Naturally a few months later his wife was pregnant. ' ' There 
remains only one more thing for you to do, " I added, ' ' and that is to 
give your child to a wet nurse if it comes into the world alive. ' ' Well, 
it was complete, because the wet nurse did not fail to be infected by 
him. 

Importance of Examination of Mate of Syphilitic. — Syphilis 
acquired in marriage does not differ in its results from syphilis 
acquired outside of marriage. It is, however, more likely to 
go unnoticed. A person taking the risks of promiscuous 
sexual relations is likely to be on the lookout for symptoms of 
syphilis or gonorrhea. This is not true in the case of the mar- 
ried person. In women, especially, the symptoms of syphilis 
are likely to be overlooked. Many times a patient will go 
through a long period of life with latent syphilis without 
noticeable symptoms. In most cases, however, the disease 
shows itself later in the form of a serious disorder. Early 
recognition, or recognition during the latent period, offers the 
opportunity to apply therapy and thus prevent serious con- 
ditions. It is for this reason that the examination of the mate 
of every syphilitic is urged. 

Types of Manifestation in Husband and Wife — Same. — The 

manifestations of syphilis may be the same in husband and 

l Fournier, A., La Syphilis des Honnetes Fernnies, p. 13. 



THE MATE 31 

wife. Thus, in both, the disease may appear to be latent and 
only be recognized as the result of the Wassermann test. 1 Or 
both may have the same very serious manifestations such as 
involvement of the central nervous system. 

Case 12. James Billings was brought to the hospital because of 
delirium tremens. A routine Wassermann test was positive. The 
wife was then examined and she also had a positive Wassermann re- 
action though neither showed any other signs of active syphilis. 

Case 13. Edward Flint acquired syphilis after he was married, and 
infected his wife. Twelve years later he came to the hospital in an 
advanced stage of nervous system syphilis. His wife was examined 
and was also found to have syphilis of the central nervous system. 
It is pleasing to be able to report improvement of the wife under 
treatment. 

Types of Manifestations in Husband and Wife — Different. — 

In many cases the disease manifestations may be quite dif- 
ferent in husband and wife. When the effects are more seri- 
ous in the person who originally acquired syphilis one is 
inclined to feel that there is more justice than when the inno- 
cent member of the pair suffers seriously while the one who 
was to blame escapes without grave results. Not infrequently 
a mate will develop heart disease, vascular disturbance, or 
central nervous system symptoms while the one who acquired 
syphilis originally remains without symptoms other than a 
positive Wassermann reaction. 

Case 14. Howard Lincoln developed a hemiplegia due to syphilitic 
vascular disease during the first year of his syphilis. The wife was 
found to have been infected but was symptom-free. She was given 
antisyphilitic treatment and at the end of four years of treatment 
her Wassermann test became negative. 

Case 15. Louis Morse after the death of his first wife acquired 
syphilis. He married again in a short time and his wife was infected 
by him. She developed general paresis and died from the disease. 
Mr. Morse developed no very grave results. After his wife's illness 
he received treatment and it is likely that he will not have any further 
trouble. 

l Throughout, when we speak of a positive or negative Wassermann reaction 
we do not, of course, refer to a single test, but to a repeated series giving a 
consistent result. 



32 SYPHILIS OF THE INNOCENT 

Frequency of Syphilis in Both Man and Wife; Psycho- 
pathic Hospital Study. — How frequently is syphilis found in 
both man and wife! To answer this and related questions a 
study was made of the families of 555 syphilitics who were in 
the late stages. This group included patients with visceral 
syphilis, latent syphilis, and involvement of the nervous 
system. 

TABLE 6. AMOUNT OF CONJUGAL SYPHILIS BY WASSERMANN 
SURVEY OF MATES OF 555 SYPHILITICS 

Number 

Total mates examined 336 

Wassermann reaction positive 98 29.2 

Wassermann reaction doubtful 7 2.1 

Wassermann reaction negative 231 68.7 

Of this group of 555 patients it was possible to get Wasser- 
mann tests on the mates of 336. Of these 336 mates, 98 or 
29.2 per cent gave positive Wassermann reactions and 7 or 
2.1 per cent gave doubtful reactions. It may therefore be 
stated that approximately 30 per cent of the mates were 
syphilitic. 

A few words may be said in order to explain the use of 
the Wassermann reaction in this study as the criterion of the 
presence of syphilis. It is a comparatively definite standard. 
While recognizing that many cases of syphilis do not give 
positive Wassermann reactions, it seemed that for statistical 
purposes it would be more accurate than a diagnosis made 
from clinical evidence alone, where there is bound to be a 
variation due to the individual equation of different exam- 
iners. As some cases of syphilis may have been missed, it 
would seem quite justifiable to state that at least 30 per cent 
or almost one out of every three of the 336 mates of syphilitic 
patients examined had syphilis. Thus, the mates of syphilitics 
offer a fertile field for the discovery of syphilis. 

How many of the syphilitic mates acquired syphilis in mar- 
riage and are therefore to be considered as cases of innocent 
syphilis, is not shown in this study. However, it may be 
assumed on the basis of our earlier analysis, that in the major- 
ity of the cases the husband acquired syphilis outside of mar- 
riage and infected his wife. Per contra, in a few cases the 



THE MATE 33 

wife was probably at fault and infected her husband; while 
in a very small percentage of cases each mate acquired syphilis 
independently outside of marriage. It is perfectly safe to 
assume, however, that the majority of the women considered 
in this study were infected by their husbands. 

Mate Usually Unaware of Infection. — As already men- 
tioned, one of the unfortunate aspects of syphilis acquired 
conjugally is that it is so often unrecognized until the late 
and serious manifestations have occurred. That most of the 
women in this group were unaware of having syphilis is shown 
by the following analysis : of the 98 syphilitic mates who had 
positive Wassermann reactions, 54 were women whom we 
were able to question as to their awareness of having syphilis. 
All knowledge was denied by 44 or 81.5 per cent of the women 
while only 10 or 18.5 per cent knew they had the disease. 

Possible Methods of Preventing Conjugal Infection. — Pre- 
marriage examination of every applicant for a marriage 
license, if such an examination could be thorough instead of 
superficial, might prevent some syphilitic marriages. If it 
did not accomplish this, it would at least indicate to the 
infected person that he or she was still syphilitic and ought 
to have the future mate under a doctor's supervision so that 
if syphilis developed later it might be cared for immedi- 
ately. The aim of all examinations is"' to get at the disease 
early, before it has made much headway. The only way to 
accomplish this in syphilis is to examine suspected cases 
even though symptom-free. This would mean that the mates 
of all syphilitics should be examined. Every doctor should 
make a strenuous effort to accomplish this examination, in 
private cases as well as in all syphilis clinics, All institutions 
such as hospitals, prisons, pauper institutions and the like 
should take a routine Wassermann test on all their inmates 
and when possible follow this up by an examination of the 
mates of the syphilitics. Unfortunately, such examinations 
are by no means routine throughout the country. Fresh evi- 
dence is constantly brought to light by the discovery of a 
syphilitic mate through the routine Wassermann test in one 



34 SYPHILIS OF THE INNOCENT 

hospital, while this same person has been at various other 
institutions previously without a suspicion of syphilis. 
Although the examination of the mate cannot prevent the 
acquiring of syphilis, by making early diagnosis possible and 
leading to treatment many of the later and more dreaded mani- 
festations can probably be prevented. One ? s sense of propor- 
tion must not be lost. Sad as are the cases of innocent women 
who are infected in marriage, we must remember that all 
women who marry syphilitic men do not acquire syphilis. The 
reasons for their escape are the converse of the reasons why 
other women acquire syphilis. The husbands either had good 
treatment or waited a long time before marrying or were very 
careful if they developed any secondary lesions. Some of the 
women might even be immune to the disease. Of the mates 
quoted in Table 6, 70 per cent escaped infection either by 
pure luck or proper care. It is well not to count at all on the 
former. Even the latter cannot insure safety, although 
naturally favoring it. 

Importance of the Conjugal Syphilis Problem. — From what 
has been said above it may be concluded that any campaign 
for the prevention of syphilis must take into consideration 
the matter of marriage. Whatever may be one's opinion 
about a syphilitic's right to marry or when he may do so, the 
fact remains that a large number cf syphilitics do marry and 
in many instances the mate is infected. Whatever laws are 
invoked in the future to reduce the risk of marital infection, 
the problem of conjugal syphilis will be with us for a long 
time to come and it is our special duty to consider and help 
these innocent victims of syphilis. 

Necessity of Examining Mates of Syphilitics. — In consider- 
ing our figure of a rate of 30 per cent of infection among mates 
it should be emphasized that in practically every instance, the 
original patient when first seen by us was in a late stage of 
the disease. Thus, in the cases in which the mate was infected 
in marriage, the infection had taken place a long period prior 
to the time our diagnosis was made. It is also implied that 
most of these patients probably had some medical inspection 



THE MATE 35 

during this long period, but in very few instances had a diag- 
nosis of syphilis been made or treatment instituted. Practi- 
cally everyone recognizes the contagiousness of the early 
stages of syphilis, and if a married person appears for treat- 
ment at this period, attention will probably be directed also to 
the mate. This is by no means so frequently done when the 
patient comes under medical care at a time far removed from 
the date of infection. If one is to do justice to the problem 
and the individuals concerned, it is necessary to examine the 
mate whether syphilis was acquired a short or a long time 
prior to the date of examination. 

REFERENCES 

Blaisdell, J. H., Menace of Syphilis of To-day to the Family of To-morrow, 

Boston Medical and Surgical Journal, vol. clxxv, no. 1, July 6, 1916. 
Bulkley, L. D., Syphilis in the Innocent, New York, Bailey and Fairehild, 1898. 
Collins, H. G., Syphilis in the Innocent, Journal of the Kansas Medical Society, 

vol. xxi, no. 1, Jan., 1921. 
Day, A. B. and McNitt, W., Incidence of Syphilis as Manifested by Routine 

Wassermann Reaction on 2925 Hospital and Dispensary Medical Cases. 

Transactions of the Association of American Physicians, Philadelphia, 

xxxiv, 1919. 
Fournier, A., La Syphilis des Honnetes Femmes. Bulletin de l'Academie de 

medecine (Seances du 2 et du 9 Oct., 1906). 
, Treatment and Prophylaxis of Syphilis, English translation, New York, 

Rebman and Co. 
Pusey, W. A., Syphilis as a Modern Problem. Chicago, American Medical As- 
sociation, 1915. 
Report of the Commission to Investigate the Extent of Feeble-mindedness, 

Epilepsy, and Insanity and Other Conditions of Mental Defectiveness in 

Michigan, 1915. 
Royal Commission of Venereal Diseases, Final Report of the Commissioners, 

London, 1916. 
Salmon, T. W., General Paralysis as a Public Health Problem, Proceedings of 

the American Medico-Psychological Association, Seventieth Annual Meeting, 

Baltimore, Maryland, May 26-29, 1914. 
Thibierge, G., Syphilis and the Army, London, University of London Press, 

Ltd., 1918. 
Vedder, E. B., Syphilis and Public Health, Philadelphia and New York, Lee 

and Febiger, 1918. 



CHAPTER III 

THE CHILD 

Congenital Syphilis; Date of Recognition. — The saddest 
aspect of syphilis is that it is transmitted to the second genera- 
tion. The child of a syphilitic may be born into the world 
with the Treponema pallidum in his body and thus be handi- 
capped through life. Like the adult who acquired syphilis, 
he may suffer any of its results. The transmission of syphilis 
from syphilitic parents to their children was recognized very 
soon after syphilis was known in Europe. As early as 1498 
Gaspard Torella 1 mentioned the existence of syphilis in new- 
born infants "propter mammas infectas." Paracelsus, 1 in 
1529, was the first to note its hereditary character: "fit 
morbus hereditarius et transit a patre ad filium." In the last 
of the eighteenth century Stoll, Planck, Von Rosenstein, and 
Sanchez 2 described syphilis hereditaria and syphilis heredi- 
taria tarda. 

Connotation of Terms "Congenital" and "Inherited." — 

When a child has acquired syphilis before or at birth he is 
said to have congenital or hereditary syphilis. There is con- 
siderable confusion in the usage of these terms and not all 
authors apply them in the same sense. Nonne 3 says that 
scientifically the term congenital rather than inherited syphilis 
should be used. The difference lies in the fact that con- 
genital syphilis is a condition in which the infection of the 
fetus occurs in utero through the agency of the treponema, 
while by the term inherited syphilis we would mean that in 
some way the germ-plasm of either parent had become affected 

1 Diday, P., A Treatise on Syphilis in New-born Children and Infants at the 
Breast, translated by G. Whitley, London, New Sydenham Society, 1859, p. 8. 

2 Pusey, W. A., Syphilis as a Modern Problem, Chicago, American Medical 
Association, 1915, p. 23. 

3 Nonne, M., Syphilis und Nervensystem, Dritte Neubearbeitete Auflage, Berlin, 
Verlag von S. Karger, 1915, pp. 690-1. 

36 



THE CHILD 37 

by the treponemal toxins. That is, without direct infection 
of the offspring, changes would have been wrought in its 
development. There are two varieties of this so-called 
inheritance of the infection: The infection may be carried 
through the placenta, or the organism may be directly bound 
to the germ cell. These two modes of infection have been 
called placental and germinal. 

We shall apply the term congenital syphilis to those cases 
in which the infection of the offspring occurred prior to or 
during birth. It will always mean in our usage that a direct 
transference of the treponema from parent to child took place 
at some period between conception and the child's existence 
independent of the body of the mother. The term hereditary 
syphilis will be used in a narrow and restricted sense referring 
to changes in the offspring due not to active and direct 
infection but to germinal defects caused by parental syphilis. 

Effects of Syphilis on Childbearing — The effects of syphilis 
on childbearing are several and vary in severity. Sterility, 
abortions, miscarriages, stillbirths, and syphilitic living 
progeny result from parental syphilis. As an illustration of 
what syphilis may do to the progeny the following case is 
given : 

Case 16. Emil Lachine was a druggist by trade and on acquiring 
syphilis thought he could treat himself. That his treatment was 
inadequate was shown by the fact that he infected his wife. He 
again attempted therapy by giving her pills and nostrums. She was 
not cured, however, and many years later bad syphilitic liver disease. 
The effect of syphilis on the next generation is quite significant. The 
first pregnancy was terminated by a miscarriage; the second one 
reached term but the child lived only five weeks. The third and 
fourth pregnancies were productive of boys who were seen by us at 
the respective ages of 19 and 15 years. Both showed numerous signs 
of congenital syphilis, were deficient mentally, and had defective 
vision. The younger child was also deaf. The fifth pregnancy re- 
sulted in a child who died at five weeks. The result of the sixth 
pregnancy was a child who was apparently normal and non-syphilitic 
when seen at 11 years of age. The seventh pregnancy produced a 
child who died at nine months. In this syphilitic family the fruition 



38 SYPHILIS OF THE INNOCENT 

of seven pregnancies was three children, two definitely feeble-minded, 
with defective vision and physical inferiority, and only one normal 
child. 

Problem of Paternal Transmission. — Having recognized the 
existence of the problem of congenital syphilis, it is expedient 
to consider the part played by one or both parents in the trans- 
mission of the disease. There is a divergence of opinion 
amongst leading authorities as to whether a syphilitic child 
can be born of a non-syphilitic mother. Can the father trans- 
mit syphilis directly to his child without infecting the 
mother? 

It should be explained that the placenta is commonly sup- 
posed to be a rather perfect filter which separates the fetus 
from the mother. On this supposition it would be possible 
for treponemata to circulate in the blood of either the mother 
or the fetus without infecting the other. To believe in 
the paternal transmission of syphilis without infection of the 
mother it must be supposed that the impregnating sperm 
carries a treponema into the uterus of the mother and attaches 
itself to the impregnated ovum, which is then sealed off, as it 
were, from the maternal organism. Treponemata arising 
from this original sperm-borne treponema would multiply in 
the fetus while the mother would remain free from syphilis. 
This view of the paternal transmission of syphilis was held 
quite generally until a comparatively few years ago. Diday 1 
and Eicord, 2 writing in the middle of the nineteenth century 7- , 
thought it quite possible for the mother of a syphilitic child 
to be non-syphilitic. Nonne, 3 at the beginning of the twen- 
tieth century, says that a woman can conceive a child by a 
syphilitic man without herself becoming infected by syphilis, 
and the fetus is then made syphilitic only by the father. 
More recent syphilologists tend to think that the mother must 
be infected in order that a child have true congenital syphilis. 
This matter has not been entirely settled. 

Ideas concerning syphilis have been materially influenced 

1 Diday, op. cit., p. 8. 

2 Ricord, Lectures on Venereal and Other Diseases, translated by V. de Meric, 
Philadelphia, 1849. 

3 Nonne, op. cit., p. 692. 



THE CHILD 39 

by knowledge of the treponema and the Wassermann test 
obtained in the last sixteen years. Realizing that syphilis 
very frequently runs a latent course during many years, espe- 
cially in women, it is seen that the mother of a syphilitic child 
may have syphilis herself, but be symptom-free. Jeans 1 took 
a Wassermann test on 85 mothers of syphilitic children. The 
Wassermann reaction was positive in 73 or 85.9 per cent. If 
a positive Wassermann reaction is to be accepted as denoting 
syphilis it would mean that at least 85.9 per cent of these 
mothers were syphilitic, although many of them showed no 
other signs or symptoms of the disease. But not every syphil- 
itic will give a positive Wassermann reaction. Of the twelve 
mothers whose reactions were negative, several showed signs 
of having had syphilis. 

This survey of Jeans therefore shows that the vast majority 
of syphilitic children have syphilitic mothers. It does not 
prove, however, that pure paternal transmission is impossible. 
Nonne 2 speaks of wives of paretics and tabetics (i.e. 
wives of syphilitics) giving birth to syphilitic children 
although they themselves were entirely free from evidence of 
syphilis including negative Wassermann tests. Dealing with 
this matter purely argumentatively it has been explained that 
such cases are instances of " burnt out syphilis' ' or " Wasser- 
mann negative syphilis.' ' 

Some modern authorities are so dogmatic in the feeling 
that every syphilitic child must have a syphilitic mother, that 
they advocate antisyphilitic treatment for such mothers 
although they show no clinical or serological signs of syphilis. 

Our own experience agrees with the foregoing of Jeans; 
namely, that in most cases the mothers of syphilitic children, 
although frequently without obvious physical symptoms of 
syphilis, have positive Wassermann reactions. 

Case 17. Ralph Jackson was a congenital syphilitic. His mother 
was apparently well but on examination showed a positive Wasser- 
mann reaction. 

There are, however, a few instances where all signs and 

i Jeans, P. C, Familial Syphilis, American Journal of Diseases of Children, 
vol. xi, no. 1, Jan., 1916, pp. 11-19. 
2 Nonne, op. cit., p. 693. 



40 SYPHILIS OF THE INNOCENT 

symptoms of syphilis including the Wassermann reaction, are 
absent. In a study of 33 mothers of 49 syphilitic children 
(see page 90) we were able to examine 25 (3 were dead, 5 not 
secured for examination). Twenty (80 per cent) had a posi- 
tive Wassermann reaction, 1 (4 per cent) a doubtful Wasser- 
mann reaction, and 4 (16 per cent) a negative Wassermann 
reaction. 

Case 18. Jacob Frank was an attractive lad of 10 years of age. 
His great drawback was stuttering. He stuttered so badly that he 
could hardly be understood. It interfered with his school work which 
was otherwise excellent. It was on this account that he sought help 
at the clinic. Physically, the boy was practically perfect. He had 
had no debilitating disease and had always enjoyed good health. He 
was the oldest of three children; there had been no further preg- 
nancies. The father and mother were both reported to be in good 
health. There was nothing in the appearance or physical findings to 
make one suspect congenital syphilis, and yet the routine Wasser- 
mann reaction on Jacob was positive. This was true on numerous 
repetitions which were made while he was under treatment. 

The father was interviewed and denied any syphilitic infection. 
However, his Wassermann was also positive. Upon learning this, he 
was ready and even overanxious to have treatment, which led to 
the suspicion that he knew of his infection. The mother was also 
examined. She showed no signs of a luetic infection nor did she give 
any history that was suggestive. A repetition of blood tests was 
entirely negative in her case. The second child in the family was 6 
years old. Like Jacob, he was a fine healthy specimen. His Wasser- 
mann was reported as doubtful. The third child, 3 years old, was 
again a perfectly normal boy who was not tested. 

Our conclusion on the question of the transmission of 
syphilis from father to child without the acquisition of 
syphilis by the mother is that it is a possibility but that if it 
occurs at all, it occurs but rarely. In a high percentage of 
cases the mother of a congenital syphilitic is herself syphilitic, 
therefore the question of treatment should be considered in 
each case. Further investigation, however, will be necessary 
before it is possible to give a categorical answer to the 
question. 

From the practical standpoint of handling the disease it is 
necessary to suspect syphilis in both parents of a congenital 



THE CHILD 41 

syphilitic. As shown by Jeans, 1 the chances of the mother's 
being syphilitic are more than 85 per cent. If the mother 
is syphilitic it is likely that the father is also, either having 
infected the mother or, what is less frequent, having been 
infected by her. Therefore, when confronted by a case of 
congenital syphilis it behooves the physician or clinic to make 
arrangements for the examination of the parents. 

Apparent Immunity of Mother of Syphilitic Child; Colles* 
Law. — At the time when belief in the doctrine of paternal 
transmission was prevalent it was noted that after the mother 
had given birth to a syphilitic child she never became infected 
by the child whom she nursed and handled, although another 
person, a nurse, was likely to become contaminated. This 
led Colles in 1837 to formulate the dictum which is now 
known as Colles' law, to the effect that when a non-syphilitic 
woman gives birth to a syphilitic child she is immune from 
infection by the child, although the child may infect another 
person. In view of the evidence of the Wassermann findings 
we agree with most current opinion that the mother is not 
infected by the syphilitic child because she is already 
syphilitic. 

Case 19. Merton Winship at the age of 10 had the definite mark- 
ings of congenital syphilis. His father was dead, but his mother was 
living. She was in good health and said she had never been really 
ill. She disclaimed any symptoms past or present, suggestive of 
syphilis. Physical examination disclosed no signs indicating that she 
was or had been syphilitic. This mother would seem to exemplify the 
law of immunity that a healthy mother giving birth to a syphilitic 
child is not infected by the child. A positive Wassermann reaction on 
her blood led to the conclusion that she was really syphilitic but had 
manifested no other signs up to that time. 

Although the vast majority of mothers who give birth to 
syphilitic children are apparently syphilitic, as demonstrated 
by physical signs or the Wassermann test, there are a few 
who show no evidence of syphilis. These mothers would bet- 
ter exemplify Colles' law, and it is upon evidence furnished 
by such cases that some authorities sponsor it. 

l Jeans, loc. cit., p. 11. 



42 SYPHILIS OF THE INNOCENT 

Case 20. Leon Shephard was 9 years of age when first seen by us. 
He was defective mentally, being classified as feeble-minded. He 
showed a moderate degree of hydrocephalus, and a strabismus which 
was said to date from the age of one year. At 3 he had had convul- 
sions. His blood and spinal fluid Wassermann reactions were positive. 
There had been one pregnancy preceding the birth of Leon which 
eventuated in a child who died at 3 months. Later the mother had 
had a miscarriage. The mother herself was quite free of any physical 
or laboratory signs pointing towards syphilis. 

Apparent Immunity of Healthy Offspring" of Syphilitic 
Mother; Prof eta's Law. — A rule of immunity relating to the 
child which is somewhat similar to Colles' law was set forth 
in 1805 by Giuseppe Profeta, namely, that an apparently 
healthy offspring of a syphilitic mother could be nursed by 
its mother or a syphilitic wet nurse and yet not be infected. 
Profeta 's conception was that these children were non-syphil- 
itic and immune to syphilis. There are two other explana- 
tions possible. First, the child may really be syphilitic 
though symptom-free. Many congenital syphilitics are 
symptom-free from birth until a number of years have elapsed 
when they are diagnosed by aid of the Wassermann reaction 
or later symptoms. These cases would not, of course, acquire 
syphilis from their mothers or from syphilitic wet nurses. 
Thus, although they may seem to bear out Prof eta's law in 
fact, they do not support his theory of immunity. 

Cose 21. Amelia Borgesi was a healthy, bright girl of 14. Her 
past history was not significant, her development having been normal 
in every way. Her mother as well as her father was syphilitic. 
Amelia, in spite of her negative history and the absence of all symp- 
toms or stigmata, had a consistently positive Wassermann reaction. 

In the second place, the mother's syphilis may be of long 
standing and no longer contagious. There are those who 
hold that all children of syphilitic mothers should receive 
treatment. This seems to us an extreme view, but it may be 
justifiable if one recalls that cases of interstitial keratitis, for 
instance, may show T their first symptoms in late adolescence 
in patients, until then, apparently non-syphilitic. In this 
connection we studied a group of 236 syphilitic women. Was- 



THE CHILD 43 

sermann tests and clinical examinations were made on the 
children. Out of 142 children who were examined 39 or 27.5 
per cent were syphilitic. The remaining' 103 or 72.5 per cent 
showed no signs or symptoms of syphilis. In view of these 
findings we feel that it would be extreme to treat all the chil- 
dren of syphilitic mothers. Our conviction is that a syphilitic 
woman may, and frequently does, give birth to healthy non- 
syphilitic children. This usually occurs late in her disease. 

Case 22. Mrs. Yogel had been unable to bring a child to term. 
She was found to be syphilitic, with the serology and the sympto- 
matology of nervous system involvement. After having antisyphilitic 
treatment, she gave birth to a child who seemed normal in all ways 
and who had a negative TVassermann reaction. The mother, who still 
showed signs and symptoms of syphilis nursed and cared for the 
child without its becoming infected. Although the mother was suffer- 
ing from syphilis she was noncontagious, both because a number of 
years had elapsed since she herself had been infected and because of 
antisyphilitic treatment. 

Conditions Accounting for Congenital Syphilis. — If pure 
paternal transmission is left out of consideration because its 
possibility is not thoroughly established, it may be stated that 
there are three situations which account for congenital syphilis. 
(1) The mother may have contracted syphilis from the child's 
father before or at the time of conception. In this case the 
child is the offspring of two syphilitic parents. (2) The 
mother may have syphilis and transmit it to her child while 
the father remains syphilis-free. (3) The mother may become 
infected during pregnancy and infect the fetus during gesta- 
tion or at the time of birth. Here the mother may have con- 
tracted syphilis from the father, from extramarital or from 
extragenital infection. In the second and third contingen- 
cies, the syphilis of the child is directly related only to the 
mother. However, as far as is known, the results are no 
different if both parents are syphilitic or if only one parent is 
so affected at the time of conception. In any case, the child's 
syphilis is innocently acquired. 

The following cases illustrate the three methods of infection 
of the child : 



44 SYPHILIS OF THE INNOCENT 

Case 23} married two years after he had contracted 

syphilis. He had had treatment for only a very short period at the 
beginning of his infection. Five years after the marriage both the 
man and his wife had strongly positive Wassermann reactions, al- 
though they showed no other symptoms of the disease. There were 
two children born of this marriage, a boy who at three years of age 
showed the signs of congenital syphilis, and a girl who had died at 
ten days of age, and is said to have had an exfoliation of the skin 
and to have turned black. She was probably syphilitic. The mother 
had been married previously and in her former marriage had five 
children, all of whom were living and well. In this family the 
syphilis acquired by the man was transmitted to his wife and then 
two syphilitic children were born. 

Case 24. Richard Shoemaker was a congenital syphilitic whose 
syphilis was diagnosed a few weeks after his birth. The parents were 
not examined until nine years later, at which time the mother had a 
positive Wassermann reaction and the father had a negative reaction 
and showed no signs or symptoms of syphilis. It is not possible to 
state absolutely definitely that the father had not been syphilitic but 
there was no evidence that he had had syphilis. This would well 
illustrate the possibility of congenital syphilis acquired through the 
mother while the father remained uninfected. 

Case 25. Jeans 2 reports two families in which the women were 
infected by their first husbands and married a second time without 
infecting their second husbands, although they continued to bear 
syphilitic children. 

Case 26. 1 While was pregnant with her third child 

her husband contracted syphilis from a prostitute and infected her. 
The child when seen at six months of age was easily diagnosed con- 
genital syphilitic. Two children born before the infection were en- 
tirely free of any signs of syphilis so that it may be concluded that 
the third child had acquired syphilis in utero, due to the infection of 
the mother while pregnant. 

i Blaisdell, J. H., The Menace of Syphilis of To-day to the Family of To- 
morrow, Boston, Medical and Surgical Journal, vol. clxxv, no. 1, July 6, 1916, 
pp. 7-13. 

2 Jeans, loc. cit., pp. 11-19, 



THE CHILD 45 

Different Manifestations in Parents and Children. — The 

severity of parental syphilis has no relation to the severity 
of the congenital syphilis. One finds parents who have had 
very grave symptoms whose children have only slight mani- 
festations or none at all; on the other hand, the children may 
be great sufferers while the parents show little besides a 
positive Wassermann reaction. 

Case 27. Adelaide Price had general paresis, the severest form of 
syphilis. Her son was a healthy, stalwart lad of about 20 who had 
never suffered any symptoms suggestive of syphilis and who would 
have been considered free from the disease but for a positive Wasser- 
mann reaction. 

Case 28. Jennie Bradford presents the opposite situation from the 
preceding family. The father and mother were well. The diagnosis 
of syphilis in the mother was reached because of a positive Wasser- 
mann reaction found after the discovery of the disease in her two 
children. Both daughters had juvenile paresis, with paralysis and 
dementia and were certain to eventuate in early death. 

The Attenuation of the Virus with Time; Kassowitz's 
Law. — An important law concerning transmission of syphilis 
to the second generation was formulated by Kassowitz in 1876. 
According to this law, the more distant the date of the infec- 
tion the more attenuated is the virus and the less evil are the 
effects on the children. For example, following the infection 
there may be a period of sterility. Pregnancies may then 
occur, which end in early abortion at from one to three months. 
Later pregnancies may lead to miscarriages at from four to 
seven months. Then a child may be born dead at term, fol- 
lowed by a living syphilitic child. The next child may show 
fewer manifestations of syphilis and after a time children 
may be born free of any sign of syphilis. This law is not 
likely to be fully exemplified in any given case, but repre- 
sents a general tendency for the earlier pregnancies to show 
more syphilitic effects than the later ones. We have made 
a study of 50 families in which syphilis occurred. No single 
case ran the entire gamut of possibilities. It was rather fre- 
quent, however, to find the severer disasters occurring first 
and the later results to be less serious. 



46 SYPHILIS OF THE INNOCENT 

Case 29. Patrick O'Brien. 
Father — syphilitic. 
Mother — syphilitic. 

1. Girl died at nine months of syphilis. 

2. Stillbirth. 

3. Boy, 16, congenital syphilis with interstitial keratitis. 

4. Boy, 13, apparently normal with a negative Wasser- 

mann reaction. 

Case 30. Mary Flynn. This family illustrates Kassowitz's law 
from the Wassermann standpoint. The father and mother were 
syphilitic. The four oldest children had positive blood Wassermann 
reactions. The next two children had doubtful Wassermann reactions, 
and the two youngest had negative Wassermann reactions. 

Jeans 1 says that in 69 of the families studied in which the 
order of pregnancies was ascertained and all of the living 
children examined, 44 families followed the rule in a general 
way although they varied more or less. "In no case was 
there a complete reversal of the rule, but in one family there 
was first a non-syphilitic child, then a negative child with a 
positive Wassermann, followed by seven stillbirths and then 
a living birth in which the child was actively syphilitic. Non- 
syphilitic children were interspersed between syphilitic chil- 
dren in seven instances in five families. For the most part 
the variation from the rule consisted of abortions following 
living syphilitic children, so that in a large measure in these 
25 irregular families Kassowitz's rule was followed." 

An analysis of any large group of syphilitic families will 
show similar variations from Kassow r itz's law. Among our 
own cases the following variations were noted among others: 
In several families there was one type of difficulty only, such 
as a series of four miscarriages, three children born alive but 
syphilitic. Frequently the syphilitic children preceded rather 
than followed the accidents to pregnancies. A long period 
of sterility was at times follow-ed by the birth of a normal 
child. In one case the first children were syphilitic, and were 
followed by a nonsyphilitic child, an accident to pregnancy 
and another nonsyphilitic child. At times the entire order 
seemed to be reversed as in the following cases: 

l Jeans, loc. cit. 



THE CHILD 47 

(1) Accident to pregnancy, non-syphilitic child, accident to preg- 
nancy, syphilitic child, accident to pregnancy, syphilitic children. 

( (2) Syphilitic child, non-syphilitic children, syphilitic child, acci- 
dent to pregnancy. 

An interesting case was reported by the Boston Dispensary, 1 
in which every other child of five was actively syphilitic 
beginning with the first. The intervening two children were 
thoroughly examined but showed no clinical or laboratory 
evidence of syphilis. 

The question of twins is pertinent in this connection. One 
would expect both of the twins to be syphilitic or non-syphil- 
itic. Post 2 reports two sets of twins, all syphilitic. Various 
cases have been reported in which one only was syphilitic. 
Still 3 reports a case of twins, one of whom died at the age of 
seven months of syphilis. The fellow twin was apparently 
healthy. Sir Herman Weber 4 notes an instance in which a 
syphilitic mother bore twin children, one of whom suffered 
with characteristic symptoms of congenital syphilis and died 
at the age of eleven weeks of diarrhea, while the other 
remained perfectly healthy. Goldenberg 5 reports one syphil- 
itic and one non-syphilitic twin. DaCosta and Van der Valk 6 
report triplets of syphilitic parentage, one of whom died at 
three weeks without any signs of syphilis, one at three years 
showed obvious signs, and the third child developed normally. 

Results of Parental Syphilis — Sterility and Accidents to 
Pregnancies. — Irrespective of the order of syphilitic accidents 
to pregnancies, it is important to keep in mind the various 
difficulties which may be attributable to parental syphilis 
before the birth of a living syphilitic child. Sterility is com- 
mon in syphilitic families, although it is impossible to show an 

1 Boston Dispensary ease reported at a meeting. 

2 Jeans, P. C, A Review of the Literature of Syphilis in Infancy and Child- 
hood, American Journal Diseases of Children, vol. 20, no. 1, July, 1920, p. 58,. 
quotes Post, American Journal Diseases of Children, vol. 12, Oct., 1916, p. 364. 

3 Still, G. F., Congenital Syphilis. (System of Syphilis, vol. I), 2nd edition, 
London, 1914, p. 287. 

4 Still, loc. cit., quotes Sir Herman Weber, p. 287. 

5 Jeans, loc. cit., p. 58, quotes Goldenberg in discussion of Wile, J., Cutaneous 
Diseases, vol. 34, Sept., 1916, p. 645. 

6 Jeans, loc. cit., p. 58, quotes DaCosta and Van der Valk, TJrologic and 
Cutaneous Beview, vol. 23, March, 1919. p. 159. 



48 SYPHILIS OF THE INNOCENT 

absolute percentage due to syphilis alone. Although, abor- 
tions, miscarriages, and stillbirths occur in non-syphilitic 
families from various causes, the number in syphilitic fami- 
lies exceeds the normal incidence. These two points will be 
taken up in detail in the chapter, "The Family," where the 
results of syphilis on the family as an entity will be shown 
by a recent study 1 of 555 syphilitic families at the Boston 
Psychopathic Hospital. It is sufficient here to note briefly 
that this study demonstrates that between one third and one 
fourth of the syphilitic parents never give birth to a living 
child. This is to be compared with the study of a similar 
group of New England families which gives only one tenth as 
being childless. More than one third of the families of syphil- 
itics had accidents to pregnancies. One fifth of the pregnan- 
cies were abortions, miscarriages, and stillbirths, as compared 
with less than one tenth of the pregnancies in non-syphilitic 
families. Syphilis thus destroys children before they have 
a chance to compete with life. 

Infant or Early Deaths. — Opinions differ as to the viability 
of children born alive in syphilitic families. It is generally 
supposed that syphilis is a frequent cause of infant deaths. 

Jeans 2 found that 22.7 per cent of the children born alive 
in 100 families were dead at the time of examination. Post 3 
in a small group of 30 families gives the percentage as 38.1. 
Julien 4 found that of 162 children born alive, 42.6 per cent 
died. In the families with congenital syphilitica or of known 
syphilitic mothers the percentage varies from 19.5 (Veeder 5 ) 
and 27.6 (Harmon 6 ) to 71.3 (Pileur 7 ). We thus see a varia- 

1 Solomon, H. C. and M. H., The Effects of Syphilis on the Family of Syphi- 
litics Seen in the Late Stages, Social Hygiene, vol. vi, no. 4, Oct., 1920, pp. 469-487. 

2 Jeans, P. C, Syphilis and Its Relation to Infant Mortality, American 
Journal of Syphilis, vol. iii, no. 1, Jan., 1919. 

3 Jeans, loc. cit., quotes Commisky, American Journal of Obstetrics, lxxiii, 1916, 
p. 676, who quotes Post. 

4 Jeans, loc. cit., quotes Holt : Diseases of Infancy and Childhood, D. Appleton 
and Co., 1916, p. 1126, who quotes Julien. 

5 Veeder, B. S., Hereditary Syphilis in the Light of Recent Clinical Studies, 
American Journal Medical Sciences, clii, 1916, p. 25. 

6 Harmon, Bishop, Final Report of the Commissioners : Report of the Com- 
mission on Venereal Diseases, London, 1916, p. 149. 

7 Vedder, E. B., Syphilis and Public Health, Philadelphia and New York, Lea 
and Febiger, 1918, p. 144, quotes Pileur. 



THE CHILD 49 

tion of from 19.5 to 71.3 per cent with a mean percentage 
between 27.6 and 38.1. It is not stated how many of these 
deaths were during infancy or later. 

In onr study of 555 families it is probable that many of the 
children who had died before examination were syphilitic, 
yet our figures for deaths are no greater than those found in 
non-syphilitic families. A review 1 of our statistics shows that 
at the time of examination approximately 20 per cent of the 
children who had been born alive had died. This agrees 
almost exactly with the figures given by the United States 
Life Table for 1910, 2 which shows that slightly more than 20 
per cent of the children born into the world do not reach the 
age of 18. We were able to obtain the age of death of 44 
children in our group/ Of these, all but one died under the 
age of 18, and this one died at the age of 19, so that it may be 
stated that these figures are absolutely comparable. Consid- 
ered from the standpoint of infant mortality, it is found that 
the infant mortality of the group born in our syphilitic fami- 
lies is less than that found in the Massachusetts Census (1915) 
which gave the infant mortality rate as 131 and 134 per thou- 
sand, respectively. The infant mortality rate in our group 
was 124 per thousand. These figures are of considerable 
interest in showing that the infant mortality rate and the 
deaths of children under 18 years of age do not vary greatly 
in the families of the late syphilitic as seen in the clinic, from 
the mortality as found in the community. 

Wirz 3 on the other hand quotes Pfaundler as showing that 
only 43 per cent of the children born living of syphilitic par- 
ents reach the age of 10, while the normal percentage is 69 
per cent. This would indicate that the death-rate from 
syphilis in the early years is greater than the normal rate. 
In spite of this we conclude from our findings that the infant 
death-rate from syphilis is not abnormally high except that, 
when added to the other effects of syphilis on the children of 
syphilitics, the deaths reduce the number of living and 

1 Solomon, H. C. and M. H., loc. eit., p. 482. 

2 Bureau of the Census, Department of Commerce, Washington, Government 
Printing Office, 1916, p. 16. 

3 Jeans, Amer. Jmr. Dis. Children, July, 1920, p. 56, quotes Wirz, Ztschr. f. 
Kinderh. 19:189 (July), 1919, who quotes Pfaundler. 



50 SYPHILIS OF THE INNOCENT 

healthy children below the norm for any family. Of course in 
any given case an infant death may well be ascribed to syphilis. 

Case 31. Margaret Miles was a syphilitic woman of 37. She 
seemed unable to bear any children who could live. In addition to 
two miscarriages, she bore five children who died in their first year. 

Congenital Syphilis — Incidence in General Child Population 
— Tables 7, 8, 9. — The last but probably most important 
aspect of the effect of syphilis on the offspring is the congen- 
ital syphilitic — the child who has weathered the very earliest 
consequences but is a syphilitic as surely as his parents. As 
in all statistics of general incidence, it is difficult to secure 
satisfactory figures for the number of children who are syphil- 
itic. The incidence of congenital syphilis may be considered 
from two viewpoints : first, the incidence in the general child 
population, and second, among the offspring of syphilitic 
parents. 

Some idea of the general incidence of congenital syphilis 
may be gained by a study of groups of children. Table 7 
gives the incidence of syphilis as shown by Wasserraann sur- 
veys in eight children's hospitals and clinics. These figures 
are open to some criticism. Clinic and hospital cases are, of 
course, selected material since they represent unhealthy chil- 
dren drawn largely from the poorer classes of the community. 
As mentioned before, the Wassermann survey is never an accu- 
rate method of determining syphilis, congenital or acquired, 
but has the value of being relatively standardized and is 
fairly satisfactory for statistical purposes, as the errors due to 
false positives and false negatives tend to cancel each other. 
In the surveys given in Table 7, 3185 children, divided among 
eight groups, were submitted to routine Wassermann tests 
and 5.2 per cent were found to have a positive reaction, indi- 
cating that syphilis was present in one out of 20 children. 
The percentages in these eight groups vary from 21.9 per cent 
at Bellevue Hospital in New York to 1.7 per cent at the New 
England Hospital for Women and Children in Boston. 

The variation between the highest and lowest figures 
is a very good warning of the care that must be used in draw- 
ing general conclusions from specific investigations. This 
cannot be emphasized too much. The percentages obtained 



THE CHILD 



51 



by ns in analyzing the figures of the two Boston hospitals, 
New England Hospital for Women and Children and the 
Boston Floating Hospital, are in point. These figures are 1.7 
per cent and 10 per cent. The children at the New England 
Hospital for Women and Children are on the whole from a 
class of higher financial rating and are less severely ill than 
those making up the patients of the Floating Hospital. Fur- 
ther, in the New England Hospital for Women and Children 
group are some new born infants whose Wassermann reactions 
would not be positive. These factors undoubtedly explain in 
part the variation in percentages. We can only conclude 
from a consideration of the figures given in the table that it is 
impossible to give a figure on the incidence of congenital 
syphilis at this time. The best we can do is to state that in 
hospital groups the incidence of congenital syphilis as shown 
by the Wassermann reaction is greater than 1.7 per cent and 
less than 22 per cent, and that it is probably about 5 per cent. 

The diagnosis of congenital syphilis based on clinical symp- 
toms excluding the Wassermann reaction cannot be consid- 
ered so accurate as when this test is the basis of the diagnosis. 
The only chance of correctly diagnosing congenital syphilis 
clinically is when the child has unmistakable stigmata or 
active symptoms at the moment of examination. In Table 
8 figures are given from several sources on the incidence 
of congenital syphilis, based upon clinical diagnosis alone. 
The percentages in these studies vary from 0.6 per cent to 3.3 
per cent, with an average of 0.9 per cent. 

That the figures given in Table 8 vary from those of 
Table 7 merely adds to the difficulty of giving an adequate 
estimate of the incidence of congenital syphilis. If any further 
proof is needed to show how badly situated one is in this 
regard, it is given in Table 9, where the figures of a Wasser- 
mann survey of four groups of children vary from per cent 
to 33.9 per cent positive reactions. To make matters worse, 
the investigators who made the study at the New Orleans 
Foundling Asylum found no children having a positive Was- 
sermann reaction but made a diagnosis of syphilis in 83.9 per 
cent of the cases based upon the luetin reaction plus clinical 
findings. The futility of attempting to be explicit in the 
present stage of our information needs no comment. 



52 



SYPHILIS OF THE INNOCENT 



Table 7. Incidence of Congenital Syphilis as Shown by Wasser- 
mann Surveys of Children's Clinic Group 



Clinic 


Number 

of 
Children 


Positive 

Wassermann 
Reaction 


Doubtful 

Wassermann 

Reaction 


Negative 

Wassermann 

Reaction 






No. 


P. C. 


No. 


P. C. 


No. 


P. C. 


Bellevue Hospital, New York 1 


191 


42 


21.9 


18 


9.4 


131 


68.6 


New England Hospital for Women 
and Children, Boston 2 


175 


3 


1.7 


1 


.6 


171 


97.7 


Floating Hospital, Boston 3 


110 


11 


10.0 


2 


1.8 


97 


88.2 


England* 6 


331 


33 


10.0 


14 


4.0 


284 


86.0 


Germany 6 * 


236 


8 


3.3 










Brooklyn, N. Y.» • 


1074 


34 


3.2 










University of California Hospital, 
California 10 


890 


26 


2.9 










New York'i « 


178 


11 


6.1 










Total 


3185 


168 


5.2 



























1 Vedder, E. B., Syphilis and Public Health, Philadelphia and New York, Lea 
and Febiger, 1918, p. 55, quotes Dr. William F. Snow. 

2 New England Hospital for Women and Children. Tests by Massachusetts 
State Department of Health. Compilation by H. C. Solomon, Boston, Mass. 

3 Floating Hospital, Boston. Tests by Massachusetts State Department of 
Health. Compilation by H. C. Solomon, Boston, Mass. 

4 Random cases. 

6 Browning, Investigations on Syphilis as Affecting the Health of the Com- 
munity, British Medical Journal, vol. i, 1914, p. 77, quoted by Vedder, p. 44. 

6 Nursing children. 

7 Epstein, Ueber die Bedeutung der Wassermannschen Reaktion in der 
Sauglingsfiirsorge, Praeger med. Wchnschr., vol. 38, 1913, p. 621, quoted by 
Vedder, p. 36. 

8 Newborn babies. Many congenital syphilitics do not give a positive Wasser- 
mann reaction at birth. 

9 Jeans, loc. cit., American Journal of Syphilis, vol. iii, no. 1, Jan., 1919, 
quotes Commisky, American Journal of Obstetrics, vol. 73, 1916, p. 676. 

io Whitney, A Statistical Study of Syphilis, Journal of the American Medical 
Association, vol. 65, 1915, 1896, quoted by Vedder, p. 61. 

11 Children without signs of syphilis. Five proved to be syphilitic and two 
possibly. Random cases. 

12 Holt, The Wassermann Reaction in Hereditary Syphilis in Congenital De- 
formities and in Various Other Conditions in Infancy, American Journal Diseases 
of Children, vol. 6, 1913, p. 168, quoted by Vedder, 'p. 72>. 



THE CHILD 



53 



Table 8. Incidence of Congenital Syphilis as Shown by Clinical 
Findings in Children's Clinic Group 



Clinic 


Number 

of 

Individuals 


Positive 

Wassermann 
Reaction 






No. 


P. C. 


King's College, England 1 


4830 


29 


.6 


Budapest, Children's Clinic 2 


106407 


720 


.66 


Children's Polyklinik, Berlin 3 


28000 


254 


.9 


Berlin 4 6 


17282 


186 


1.07 


Germany 6 


17448 


207 


1.18 


Hospital for Sick Children, England 7 


12000 


250 


2.5 


Children's Memorial Hospital, Chicago 8 


695 


23 


3.3 


Southern Clinic 9 10 


225 


7 


3.1 


Total 


186887 


1676 


.89 



1 Still. G. E., Congenital Syphilis, London, (System of Syphilis, vol. i), second 
edition, 1914, p. 290. 

2 Pusey, op. cit., quotes Vas, p. 70. 

3 Heller, Die Hauflgkeit der Hereditaren Syphilis in Berlin, Bed. Jclm. 
Wchnschr. xlvi, 1909, p. 1315, quoted by Vedder, p. 36. 

4 Nursing children. 

5 Griffith, J. P. C, The Diseases of Infants and Children, Philadelphia, 
Saunders, 1919, quotes Fruhinholz, p. 562, Eev. d'Hyg. et de med. inf., vol. ii, 
no. 1, 1903. 

6 Heller, quotes Von Cassel, quoted by Vedder, p. 36. 

7 Still, G. F., op. cit,, quotes R. J. Lee, vol. i, p. 290. 

8 Churchill and Austin, Frequency of Hereditary Syphilis, American Journal 
Diseases of Children, vol. 12, 1916, p. 355, quoted by Vedder, p. 72. 

9 White children only. 

io Moore, Hereditary Syphilis in the Negro Race, Southern Medical Journal, 
vol. 8, 1915, p. 946, quoted by Vedder, p. 91. 



54 



SYPHILIS OF THE IXXOCEXT 



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THE CHILD 



55 



Congenital Syphilis — Incidence in Syphilitic Families. — 

How many syphilitic parents pass on their syphilis to their 
children is a more pertinent question. Our study of 555 syph- 
ilitic families 1 demonstrated that the percentage of syphilis 
in the children, as shown by the Wassermann test, lay between 
8.4 per cent (191 families) and 16.7 per cent (364 families), 
according to the method of selection. That is, between one in 
twelve and one in six of the children examined showed evi- 
dence of syphilitic disease. This is brought out in Table 10. 

Table 10. The Amount of Syphilis in Children 



Class 


191 Families in 
which Every Liv- 
ing Member was 
Examined 


364 Families in 
which One or 
More Members 
Besides the Pa- 
tient was Ex- 
amined 


555 Families 

Total of 191 

AND 364 




No. 


P. C. 


No. 


P. C. 


No. 


P. C. 


Total children examined 


202 


100 


221 


100.0 


423 


100.0 


Total children negative 


179 


88.6 


181 


81.9 


360 


85.1 


Total children doubtful 


6 


3.0 


3 


1.4 


9 


2.1 


Total children positive 


17 


8.4 


37 


16.7 


54 


12.8 



A review of the literature concerning the prevalence of con- 
genital syphilis in syphilitic families gives figures varying 
greatly from the above. This variation is undoubtedly due 
to a different method of selection of syphilitic families. Post, 2 
in a survey of 30 families based upon his clinical judgment, 
gives the incidence of syphilis in the living children of these 
families as 45.1 per cent. Hochsinger 3 in a similar survey of 
134 families, gives the incidence of congenital syphilis as 
83.2 per cent. Plaut and Goring 4 in a Wassermann survey of 
54 families place the incidence of positive reactions at 26 per 
cent. Of these reports, only that of Plaut and Goring was 
made in a manner at all similar to ours, that is, by a Wasser- 

1 Solomon, H. C. and M. H., op. cit., p. 479. 

2 Jeans, op. cit., p. 676, quotes Post. 

3 Hochsinger, Die Gesundheitlichen Lebensehicksale, Wiener Minische Wochen- 
schrift, vol. 24, June 16, 1910, p. 882. 

4 Plaut und Goring, Untersuchungen an Kindern und Ehegatten von Paralytiken, 
Munchener medizinische Wochenschrift, vol. 58, no. 37, Sept. 12, 1920, p. 1959. 



56 SYPHILIS OF THE INNOCENT 

mann survey, and their percentage runs considerably higher 
than ours. Of course, they studied a much smaller group, and 
it is not certain that the examinations were routine or made 
on unselected families. It is desirable to make perfectly clear 
that our figures are based on the examination of the children 
of families in which one parent was known to have syphilis. 
In many instances this was the father, and the mother was not 
infected so far as known. The figures which we offer give an 
accurate account, we believe, of the results of a Wassermann 
survey made in this fashion. 

Many of the studies reported in the literature use the term 
4 ' syphilitic family" without defining the method of selection. 
If families are selected in which the mother is known to be 
syphilitic, the results are quite different from those obtained 
from families in which either the mother or father is syphil- 
itic. Thus, in our group of 555 families there were 236 women 
known to be syphilitic. A study of the families of these 236 
syphilitic women gives somewhat different results from those 
based upon the study of 555 families, including families in 
which the mother was not syphilitic and only the father 
showed signs of syphilis. As mentioned above (page 43), 142 
children born in this group of 236 families were examined, 
and 39, or 27.5 per cent gave positive Wassermann reactions. 
This figure is to be compared with 12.8 per cent which is the 
percentage of positive Wassermann reactions occurring in 
the children examined in the total group of families (555). 

Incidence of Living Non-syphilitic Children in Syphilitic 
Families. — Having taken up accidents to pregnancies, infant 
deaths, and syphilitic children separately, it is of interest to 
note how many of the pregnancies resulted in living non- 
syphilitic children. Again our figures show a higher propor- 
tion of healthy children than other studies, owing to the uncon- 
scious selection of a "syphilitic family" as one in which the 
original patient was a congenital syphilitic or a syphilitic 
mother. One congenital syphilitic suggests the possibility 
of a second; the known syphilitic mother is apt to have syphil- 
itic children. It is to be remembered that the children in our 
study were the children of an unselected group of adult late 
syphilitics, a group exclusive of congenital syphilitics as 



THE CHILD 57 

original patients and in which the large majority of original 
patients were men who may or may not have infected their 
wives. 

Post 1 gives the living and healthy children as only 23.2 per 
cent; Hochsinger, 2 9.3 per cent; Julien, 3 20.9 per cent; Veeder, 4 
11.4 per cent; and Harmon, 5 20.9 per cent. The last two are 
for families of congenital syphilitics. Omitting these, the 
range is from 9.3 per cent to 23.2 per cent. We find that of 
342 pregnancies in the 191 families in which every living mem- 
ber was examined, 179 or 52.3 per cent resulted in healthy 
children. Comparing onr figures with non- syphilitic families 
we naturally find that there are many more living and healthy 
children in the latter. For instance, Jeans 6 gives 75.5 per 
cent, Harmon 5 79.2 per cent, and a study of conditions in 
Johnstown, Pennsylvania, 7 78.4 per cent, of healthy children 
in non-syphilitic families. We feel that the toll of syphilis, 
though not as heavy as some might say, is severe enough 
when it reaches practically 50 per cent of the pregnancies. 

Symptoms of Congenital Syphilis. — The symptoms of con- 
genital syphilis are so varied that only the most conspicuous 
are recognizable to the layman and many are ignored by the 
physician who has not specialized in syphilis. In the follow- 
ing table many of the symptoms described in the textbooks 
as symptoms of congenital syphilis are given, and the more 
characteristic are italicized: 

1 Jeans, op. cit, quotes Commisky, American Journal of Obstetrics, vol. 5, no. 
73, 1916, p. 676, who quotes Post. 

2 Habermann, Hereditary Syphilis, Journal of the American Medical Associa- 
tion, vol. 64, no. 14, April 3, 1915, p. 1141, quotes Hochsinger. 

3 Jeans, op. cit., quotes Holt, Diseases of Infancy and Childhood, D. Appleton 
and Co., 1916, p. 1126, who quotes Julien. 

4 Veeder, Hereditary Syphilis in the Light of Clinical Studies, American 
Journal Medical Sciences, vol. 152, 1916, p. 522. 

5 Harmon, op. cit., p. 149. 

6 Jeans, P. C. and E. Butler, Hereditary Syphilis as a Social Problem, Ameri- 
can Journal of Diseases of Children, Nov., 1914. 

7 Infant Mortality Series No. 3, Children's Bureau Publication, no. 9, Wash- 
ington, D. C, 1915. 



58 



SYPHILIS OF THE INNOCENT 



Table 11. Symptoms of Congenital Syphilis 



I. Integument. 

1. Skin — rashes, pemphigus, condy- 
loma, gumma, erythema, dry skin, 
rhagades, furunculosis, phage- 
denic ulcerations, palmar and 
plantar syphilides, thickening, 
pigmentations, leucoderma. 

2. Haii" — alopecia, excessive amount. 

3. Teeth — imperfect primary, sepa- 
ration, notched, Hutchin-sonian, 
abnormally placed and shaped, 
suppuration of tooth sac. 

4. Nails — inflammation of matrix, 
onychia. 

II. Eyes. 

1. Interstitial keratitis. 

2. Iritis. 

3. Retinitis. 

4. Choroiditis. 

5. Choroido-retinitis. 

6. Opacities in vitreous. 

7. Nystagmus. 

8. Optic atrophy. 

III. Ears. 

1. Otitis media. 

2. Otitis interna. 

IV. Respiratory tract. 

1. Snuffles. 

2. Saddle nose. 

3. Ozena. 

4. Tracheitis — hoarse voice. 

5. Tracheal stenosis. 

6. Pneumonia alba. 

7. Gumma. 

V. Gastro-intestinal tract. 

1. Marasmus — disturbance of nutri- 
tion. 

2. Glossitis. 

3. Stomatitis. 

4. Tonsillitis. 

5. Pharyngitis. 

6. Pyloric stenosis. 

7. Cirrhosis of liver — jaundice — 
ascites. 

8. Gumma of liver. 

9. Cirrhosis of pancreas, 
10. Enlargement of liver. 



VI. Cardiovascular-lymphatic. 

1. Myocarditis. 

2. Congenital heart disease. 

3. Endarteritis. 

4. Aneurysm. 

5. Anemia. 

6. Splenic anemia. 

7. Adenitis — enlargement of glands. 

8. Hemorrhage of the new born. 

9. Edema without albuminuria. 
10. Splenitis. 

VII. Genito-urinary. 

1. Nephritis — albuminuria. 

2. Hemoglobinuria. 

3. Hydrocele. 

4. Orchitis. 

5. Epididymitis. 

VIII. Nervous system. 

1. Feeble-mindedness. 

2. Juvenile paresis. 

3. Juvenile tabes. 

4. Microcephalus. 

5. Hydrocephalus. 

6. Cerebral aplasia and agenesia. 

7. Meningo-encephalitis. 

8. Spastic palsies — cerebral and 
spinal, hemiplegia, diplegia. 

9. Epilepsy — convulsions. 
10. GAimma — tumor. 

IX. Endocrine system. 

1. Infantilism — late puberty. 

2. Old man appearance. 

3. Stunted growth. 

X. Bones and joints. 

1. Osteitis. 

2. Epiphysitis. 

3. Periostitis. 

4. Osteomalacia. 

5. Cranio — tabes (Parrot's nodes). 

6. Bossing of skull. 

7. Fragilitas ossknn syphilitica. 

8. Sabre tibia. 

9. Pseudo-paralysis. 

10. Bony thickening — Heberden's 
nodes. 

11. Chronic synovitis with effusion. 

12. Suppuration into joints. 

13. Synovitis. 



THE CHILD 59 

Symptoms and Diagnosis — Date of Appearance — It must 
be remembered that these symptoms are indicative of various 
forms of syphilis and that only a few are present in each case, 
depending on the type of syphilis. Many are symptomatic 
also of diseases other than congenital syphilis. Some, such 
as interstitial keratitis, early nerve deafness, and Hutchin- 
sonian teeth, known as the Hutchinsonian triad, are very sug- 
gestive and, in combination, are definitely diagnostic of 
congenital syphilis. In addition, one might mention hydrops 
articulorum, saddle nose, Olympic forehead and sabre tibiae. 
Many people erroneously feel that if a child has seemed to 
escape without early symptoms (often present but undiag- 
nosed) the danger line has been passed. But the symptoms 
of congenital syphilis may appear at any age — in babyhood, 
childhood, early or late adolescence, or even in adult life. 

Clinical Manifestations. — The clinical manifestations of 
congenital syphilis are as numerous and varied as in acquired 
adult syphilis except that congenital syphilitics do not pass 
through the primary stages as do children or adults who 
acquire syphilis. Some congenital syphilitics go through life 
with hardly a symptom or sign. Others are led to early death, 
while there are many children who live and develop all sorts 
of grave conditions. 

Early Symptoms. — A syphilitic infant may show symptoms 
shortly after birth. The symptoms of this period correspond 
to those of the secondary period of the disease in the acquired 
form. Among the common early symptoms are snuffles, skin 
rashes, abnormalities of the nails and hair. The infant may 
be born with these manifestations or they may appear after 
an interval of a week or more. They may vary considerably 
in intensity from very insignificant redness of the skin to a 
pemphigus leading to death. When the reaction is marked 
the diagnosis is made with ease, but in many of the milder 
types it is hardly possible to base a diagnosis on the clinical 
appearance. 

Marasmus or emaciation, dependent on poor assimilation 
of food, is a rather common result of congenital syphilis. 



60 SYPHILIS OF THE INXOCENT 

These cases prove very recalcitrant to ordinary feeding regu- 
lations and are likely to die if not saved by antisyphilitic 
treatment. The Wassermann reaction offers very little assist- 
ance in the diagnosis, as it is usually still negative in the early 
days of life. There is some evidence to show that the Wasser- 
mann reaction of the mother's blood is also likely to be 
negative shortly after delivery. 

Changes in the enamel plate of the teeth date back to intra- 
uterine life, or early infancy, although they are not seen until 
a number of years later when the permanent teeth are erupted. 
Bone changes also probably start very early but are noticed 
only much later in the form of changes in the long bones, as, 
for example, sabre tibiae; in the flat bones as bosses of the 
skull, epiphyses, and fontanelles. 

Danger of Death in First Year. — The first year is the danger 
period for congenital syphilitics with severe early lesions. 
Death may occur from any one of several causes. The dis- 
turbance in the respiratory tract shown by snuffles may pro- 
gress and lead to broncho-pneumonia. The lesions of the 
skin may be very serious and produce a fatal pemphigus. 
Inanition or marasmus may result in death. Hemorrhage of 
the newborn may be of syphilitic origin and prove fatal. The 
same is true of liver disease. Thus, the infant with an active 
syphilis has a terrible handicap in meeting the vicissitudes of 
early life. 

Importance of Immediate Treatment. — Treatment has a 
great deal to offer in these cases, and the sooner it is insti- 
tuted the better are the chances of therapeutic success. Even 
at the best, however, there are cases which cannot be saved 
by treatment. 

Case 32. Paole and Maria Gallioni, 1 aged 24 and 22, respectively, 
were found to be syphilitic. They were examined as the parents of 
their six-months old son, who was a typical congenital syphilitic with 
an enlarged liver and spleen, rash on the face, palms of the hands, 
and soles of the feet. The woman had had two miscarriages followed 

l Children 's Hospital, Boston. 



THE CHILD 61 

by this syphilitic baby. The doctor who confined her did not suspect 
syphilis then or later when the baby had a rash. If this woman had 
had a Wassermann test during her pregnancy, adequate treatment 
might have saved the baby. As it was, the treatment was started at 
the age of six months. The baby improved for four months but died 
of broncho-pneumonia and encephalitis. The parents were very 
cooperative about the baby's treatment and their own. 

Case 33. Sarkis Sculos. Preceded by three miscarriages, Sarkis 
was born at term but was very sickly, had snuffles and a rash. He 
was treated with mercury for some time and improved. At the age 
of 6 he developed interstitial keratitis and then developed a left-sided 
hemiplegia which persisted. 

Case 34. Bertram Wood was a syphilitic who infected his wife. 
The first child was a blind syphilitic who died of marasmus at the age 
of five months. The second child was a living syphilitic. Al- 
though the original patient was aware that he had contracted syphilis 
he did not know that he had infected his wife, nor was syphilis diag- 
nosed at the death of the baby. 

Latent Congenital Syphilis— The vast majority of congen- 
ital syphilitics do not show marked and easily recognizable 
symptoms in infancy. Many are born in perfect condition 
and develop normally through, infancy and early childhood 
or even to adult life. Not only may no active symptoms be 
present, but there may be no suspicious stigmata. Neverthe- 
less, many of these children will later show serious syphilitic 
disorders. The story is the same as in acquired syphilis; 
there is an apparently latent period during which no symp- 
toms are manifest. The Wassermann test has been very help- 
ful in picking out these cases of congenital syphilis. 

Case 35. Esther Kroll was the daughter of syphilitic parents. Her 
mother was a patient in a hospital for the insane, suffering from 
general paresis. Her father had a positive Wassermann reaction, 
but no recent symptoms. Esther when first seen was 14 years of 
age and apparently hi the best of health. She was a very attractive 
looking girl, well developed for her age, and the picture of health, 
with rosy cheeks and all the lightness of temperament and joy of 
living that is supposed to go with healthy youth. According to her 
history, she had always been entirely well, and developed normally. 
She was of rather superior intelligence. Physical examination showed 



62 SYPHILIS OF THE INNOCENT 

no evidence of syphilitic or other stigmata. Her blood Wassermann 
test, however, was strongly positive, and remained so on several sub- 
sequent tests. This Wassermann reaction and the history were the 
only evidence of syphilis. 

Some children with congenital syphilis may not show any 
active symptoms of syphilis that would lead to considering 
them as sick and yet they may have stigmata allowing a diag- 
nosis of congenital syphilis to be made at a glance. Charac- 
teristic Hutchinsonian teeth, frontal bosses, and saddle nose 
may give the unmistakable facies of a congenital syphilitic 
to a child who has been apparently healthy and has suffered 
no discomfort from syphilis. Such cases are much more 
likely to receive treatment than those which, show no stigmata, 
and thus they have a better chance of escaping the late 
manifestations. 

Case 36. Marcia Burns was 9 years of age when she was diagnosed 
a congenital syphilitic. She was easily recognizable as such. Among 
the signs marking her as a congenital syphilitic were prominent 
frontal bosses, serrated teeth, incisors of the crescent form, scaphoid 
scapulae, and defective vision. She had suffered no clinical symptoms 
diagnostic of congenital syphilis although she was known to be 
nervous. The Wassermann reaction was positive and treatment was 
instituted. 

Lues Hereditaria Tarda. — Although a child may have 
escaped for many years without any symptoms of syphilis 
this is no indication that he has established an immunity or 
will not sutler later. Indeed, much of the symptomatology of 
congenital syphilis is seen during puberty and adolescence in 
children who have previously been apparently well. Nonne 
feels that the symptoms appear more frequently at the time 
of puberty. Fournier, 1 in an analysis of 212 cases, found that 
the date of appearance of S3'mptoms varied in different 
patients between three and twenty-eight years, with an 
appearance at the average age of twelve years. Charcot 2 
even saw one case in whom symptoms first appeared at thirty 

i Fournier, A., La Syphilis Eereditaire Tardive, Paris, G. Masson, 1896, p. 180. 
2 Charcot, M., Clinique des Maladies du Systeme Nerveus, Paris, Veuve Babe et 
Cie, 1892 1 , chap. xix. 



THE CHILD 63 

years. These cases have been referred to in the literature as 
instances of lues hereditaria tarda, which may be translated 
as late symptoms of congenital syphilis. All the symptoms 
given on the symptom chart, with the exception of a very few, 
as snuffles, pemphigus, and marasmus, are seen in the late 
years of childhood. These late symptoms may occur in the 
children who have had no early symptoms as well as in those 
who have weathered early difficulties; apparently healthy 
children, free from stigmata, may suffer from the severest 
forms of late syphilis just as those who are markedly 
stigmatized or those who have shown symptoms throughout 
life. 

Interstitial Keratitis. — The sensory organs are very fre- 
quently involved. Syphilis is a fairly common cause of eye 
trouble. Derby and Walker, 1 in an analysis of 77,000 new 
cases of eye disease at the Massachusetts Charitable Eye and 
Ear Infirmary, find that .4 per cent of the cases had interstitial 
keratitis. They quote Hoor's German statistics showing that 
in 475,000 cases of eye trouble, interstitial keratitis occurred 
3026 times or .63 per cent. Thus it means that about one case 
of eye disease in every 200 is a result of congenital syphilis. 
In the late stages of congenital syphilis, interstitial keratitis is 
one of the most important of the symptoms. It is important 
both from the standpoint of diagnosis and of its effect on the 
patient. There is so much about it that is characteristic that 
it affords great assistance in making diagnoses. It is marked 
by an involvement of the cornea of the eye. The eye becomes 
much inflamed and ulcers are likely to appear. Frequently the 
ulcers, when healed, leave scars upon the cornea on that por- 
tion directly over the pupil. Interference with vision results. 
Interstitial keratitis occurs most frequently between the ages 
of eight and fifteen, although it may be seen from six to 
thirty. As a rule the activity is self -limited and healing with 
more or less scar formation occurs spontaneously in a period 
of from a few days to a number of months. A succession of 
attacks is frequent and both eyes are usually involved. Inter- 

l Derby, G. and C. B. Walker, Interstitial Keratitis of Luetic Origin, Transac- 
tions of the American Ophthalniological Society, 1913. 



64 SYPHILIS OF THE INNOCENT 

stitial keratitis may occur in individuals showing other signs 
of congenital syphilis. On the other hand, it occurs in cases 
that are quite free from any other syphilitic stigma. It is not 
infrequently associated with other syphilitic diseases of the 
eye, such as choroiditis and retinitis, while iritis is nearly 
always present. 

Aside from possible blindness the condition is of consider- 
able consequence on account of the discomfort of the patient 
during the attack. Photophobia, that is, pain when the eye 
is exposed to light, is practically always present, as well as 
profuse discharge. This means that the patient suffers 
considerably and needs special care. 

Case 37. Susan Shea developed interstitial keratitis at the age of 
14. Previous to this period she had been quite well. She was given 
antisyphilitic treatment at once and her eyes improved so that she 
recovered without blindness. Her father had acquired syphilis one 
year before her birth. 

Case 38. Francis Defararri was first seen by us at the age of 15. 
He had been in an institution for the blind since he was about 7 years 
of age. The visual defect was caused by scars on the cornea over the 
pupillary opening which prevented light rays from reaching the 
retina. These scars were the result of an old interstitial keratitis. 
This boy was blind as a result of congenital syphilis. It is quite 
possible that had he received early treatment the blindness could 
have been prevented. 

Case 39. Frederick "Waters was 20 years of age at the time he first 
visited the clinic. He was referred by the ophthalmologist because 
of interstitial keratitis. As was to be expected, the Wassermann re- 
action of his blood was positive. There were no other symptoms of 
congenital syphilis. A careful examination did not bring forth any 
evidence of luetic symptoms such as might have been expected had 
the disease been acquired. Waters had been married for three years, 
his wife was free from syphilis and had given birth to two normal, 
healthy children. Therefore, it seems fair to assume that this is a case 
of congenital syphilis in which interstitial keratitis appeared as the 
first symptom of the disease when the patient was 20 years of age. 

Other Forms of Involvement of the Eye. — Aside from inter- 
stitial keratitis there are various other types of congenital 
syphilitic involvement of the eyes. Choroidoretinitis is a form 



THE CHILD 65 

that is fairly characteristic of congenital syphilis, and fre- 
quently offers the opportunity of making a diagnosis. In many 
instances this condition leads to blindness. Cataracts occur- 
ring in infants or young children are nearly always caused 
by congenital syphilis. Optic atrophy is found in cases of 
congenital syphilis as well as in the acquired form. The optic 
nerve is closely related with the central nervous system, and 
as a rule cases with optic atrophy will show other evidences 
of central nervous system invasion. The situation is similar 
to that seen in the acquired form when one speaks of optic 
tabes. When once optic atrophy has started it is practically 
always progressive, leading to complete blindness. Strabismus, 
nystagmus, and the like are also frequently present. 

Case 40. Albert O'Connors became blind at the age of 5 years. 
At the same time he developed strabismus. The blindness proved to 
be due to an optic atrophy. He was placed in a school for the blind 
but was incapable of making progress and it was found that in addi- 
tion to his blindness he was feeble-minded. The blindness was defi- 
nitely caused by congenital syphilis as was probably the feeble- 
mindedness. 

Case 41. Lucia Petrofski was brought to the hospital by her teacher 
because of headaches, pains in her back, and defective vision. Ex- 
amination showed that she was a congenital syphilitic. Her visual 
difficulty was due to a syphilitic choroiditis. 

Deafness. — Deafness is a fairly common symptom of late 
congenital syphilis. The combination of interstitial keratitis 
and nerve deafness is not unusual. Any part of the auditory 
apparatus may be involved. The important point is that the 
condition is progressive and quite resistent to any form of 
treatment. 

Case 42. Louis Lachine was the second living child in a family 
which showed the ravages of syphilis to a very marked extent. The 
mother had syphilitic cirrhosis of the liver. The first pregnancy was 
a miscarriage, the second was a child who died at five weeks, the 
third was a boy who showed innumerable symptoms and stigmata of 
congenital syphilis including Hutchinsonian teeth and interstitial 
keratitis. Then came the patient who was followed by another child 
who died at five weeks. The sixth pregnancy gave rise to a boy who, 



66 SYPHILIS OF THE INNOCENT 

aside from being retarded mentally, showed no disorders. The last 
child died at nine months. 

The patient under consideration was first seen by us at the age of 
15, at which time he was completely deaf. He had a positive blood 
"Wassermann reaction and was feeble-minded. He was partially blind 
as the result of an old interstitial keratitis which occurred at the age 
of 12. He had Hutchinsonian teeth and in addition to the deafness 
he gave evidence of involvement of the vestibular portion of the 
eighth nerve, staggering and swaying in his walking. 

Involvement of the Bones. — Involvement of the bones occurs 
at times, but is not very characteristic of congenital syphilis. 
Kather than helping to make a diagnosis it usually offers dif- 
ficulties and often leads to erroneous diagnoses. The form 
of bone involvement may vary in different cases. The type 
leading to the formation of the so-called sabre shin is, of 
course, quite easily recognized. Pain is frequently present, 
due as a rule to periostitis. At other times gummatous 
lesions of the bone occur which may end in osteomyelitis. 

Case 43. Mary Mazzocca was the sixth child in a syphilitic family. 
The mother had had nine pregnancies. Besides Mary, there was one 
other living child who was a juvenile paretic. Mary was 17 years old 
when seen by us. She had had interstitial keratitis from which she had 
made a fairly good recovery. The history and examination showed 
that she had had a great many bone lesions. There were scars in 
various portions of the body where the skin had broken down as a 
result of an underlying bone lesion. These scars appeared on the 
frontal bone of the skull, on the arms and legs. A diagnosis of tuber- 
cular osteomyelitis had been made. The case seems to be one in 
which the congenital syphilis was the provocative agent in the pro- 
duction of the bone lesions as well as of the interstitial keratitis. 

Hydrops articulorum, a form of swelling of the knees caused 
by suffusion with fluid, is another very characteristic symp- 
tom of congenital syphilis, oftentimes occurring in conjunc- 
tion with interstitial keratitis. The condition is usually 
bilateral, self -limited, with a tendency to recur. 

Congenital Syphilis and Feeble-mindedness. — The relation 
of syphilis to feeble-mindedness presents a question that is not 



THE CHILD 



67 



easily answered. It is obviously true that there are a certain 
number of congenital syphilitics who are feeble-minded 
because of destructive lesions or failure of development of the 
brain due to congenital syphilis. However, a congenital 
syphilitic may have a coexistent feeble-mindedness which is 
hereditary, that is due to the presence of feeble-mindedness in 
the family or caused by other conditions than syphilis. Most 
feeble-minded children are not syphilitic and most congenital 
syphilitics are not mentally retarded. 

Incidence of Congenital Syphilis Among the Feeble- 
minded — Table 12. — The accompanying table gives the result 
of a number of Wassermann surveys of children in institutions 
for the feeble-minded: 

Table 12. Prevalence of Syphilis Among the Feeble-minded 



Clinic 


Number 
of In- 
dividuals 


Positive 

Wassermann 
Reaction 


Interpretative Data 




No. 


P. C. 




Mass. School for Feeble-minded 1 


1565 


70 


4.5 


Feeble-minded children 


Institution for Feeble-minded, Co- 
lumbus, Ohio 2 


1550 


132 


8.5 


Presumably congenital feeble- 
minded cases. No history of 
infection 


School for Feeble-minded, Minn. 3 


600 


16 


2.6 


Feeble-minded boys. Weak an- 
tigen, so few positive 


Institution for Feeble-minded , Balti- 
more, Md. 4 


480 


14 


less 
than 
3.0 


Feeble-minded boys and girls 


Randall's Island, N. Y.* 


204 


30 


14.7 


Feeble-minded boys and girls, 
140 under 20 years 


Total 


4399 


262 


6.0 





1 Wassermann Tests (blood taken by H. C. Solomon) at the Massachusetts 
School for Feeble-minded. 

2 McKay, Inherited Syphilis in Feeble-mindedness, Illinois Medical Journal, 
vol. 28, 1915, p. 281, quoted by Vedder, p. 75. 

3 Moulton, Wassermann Test on 600 Cases of Feeble-minded at the Minnesota 
School for Feeble-minded and Colony of Epileptics, Journal of Psychoasthenics, 
vol. 18, 1914, p. 222, quoted by Vedder, p. 75. 

4 Walker, Symposium on Syphilis, Congress of American Physicians and 
Surgeons, 1916, Journal American Medical Association, vol. 66, 1916, p. 1740, 
quoted by Vedder, p. 73. 

5 Atwood, C. E., Idiocy and Hereditary Syphilis, Journal American Medical 
Association, vol. 55, August 6, 1910, pp. 464-465. 



68 SYPHILIS OF THE INNOCENT 

The average of the figures given in the table shows that 
the Wassermann reaction is positive in 6.0 per cent of the 
children surveyed in the institutions for the feeble-minded in 
America. It is to be compared with the average of syphilis 
among hospital children (see page 52), which came to about 
5 per cent. The small difference between 6 per cent and 5 
per cent allows for no very definite conclusions. Goddard 
has called attention to the fact that feeble-mindedness is often 
hereditary, that it frequently disposes persons to conduct 
which might lead to the acquisition of syphilis. Hence it is 
possible that the parents of many of the children in the feeble- 
minded schools are themselves syphilitic, and thus their chil- 
dren would have a higher percentage of syphilis than a normal 
group. In this case it would follow that there would be a 
higher percentage of congenital syphilis in the offspring of 
the feeble-minded than in the offspring of a normal group. 
Therefore, it is not possible to state, as is so often done, that 
congenital syphilis is a great element in the production of 
feeble-mindedness. 

Case 44. The Johnson family illustrates the care that one must 
use in concluding that cases of congenital syphilis and feeble-minded- 
ness are causally related or that one is definitely dependent upon the 
other. The mother and father in this family were syphilitic. There 
were five children ranging in age from 10 years to 6 months. The 
four older children had positive Wassermann reactions and signs of 
congenital syphilis. The fifth child was not examined. The three 
older children were definitely retarded mentally and could well be 
classified as feeble-minded. No decision was reached in the cases of 
the fourth and fifth children as they were quite young. There were 
then, at least three children suffering both from congenital syphilis 
and feeble-mindedness. However, both the father and mother, were 
feeble-minded. The feeble-mindedness of these children was not 
caused by the syphilis. The feeble-mindedness of the parents existed 
prior to the acquisition of syphilis and it is more probable that their 
children were feeble-minded as a result of the feeble-minded rather 
than the syphilitic heredity. In other words, they were the feeble- 
minded offspring of feeble-minded stock. 

On the other hand, there seems to be little chance for doubt 
that certain individual cases of feeble-mindedness owe their 



THE CHILD 69 

origin to syphilis in the parent. Thus, where the heredity is 
free from mental disorder or feeble-mindedness, where there 
have been no prenatal or postnatal accidents, and yet the child 
is a congenital syphilitic with evidence of disordered develop- 
ment, one may often conclude that congenital syphilis is the 
etiological factor in the feeble-mindedness. 

Case 45. Helen Paglia had had minor difficulties at school and 
was brought to the hospital by the S. P. C. C. She was 14 years old 
but her mental age was 11. She was diagnosed feeble-minded. Ex- 
amination disclosed a positive Wassermann reaction. The family 
history showed a parental syphilis but no feeble-mindedness. It is, 
therefore, conceivable that there is some connection between the con- 
genital syphilis and the lowered mentality. 

Case 46. Julius Swartz was a very good-looking child of 6 years 
who was very definitely feeble-minded. His father was a tabetic, his 
mother quite well, with a negative Wassermann reaction. There was 
one older brother who was very bright but showed a number of 
peculiar dystrophies. Julius was born at full term with normal de- 
livery. He is said to have had cholera infantum when 6 years of age 
associated with broncho-pneumonia. At 5 he had whooping cough, 
otherwise the past history was entirely negative. He presented a few 
signs suggestive of congenital syphilis as well as a positive Wasser- 
mann reaction in the blood serum. This family is entirely free from 
any history of mental disorder including feeble-mindedness. It there- 
fore seems quite likely that the feeble-mindedness in the case of 
Julius is associated with the fact that he is suffering from congenital 
syphilis. 

Incidence of Feeble-mindedness in Syphilitic Families. — 
Another way of determining the effect of congenital syphilis 
on the production of feeble-mindedness is to consider the fre^ 
quency of feeble-mindedness in syphilitic families. Jeans and 
Butler 1 made a study of the families of 83 syphilitic children. 
They found that 20 per cent of the families had one or more 
defective children. For purposes of comparison, a study of 
the families of 100 children who were in the hospital because 
of infectious diseases was made. Defective mentality was 
found in only 4 per cent of these families. 

i Jeans and Butler, op. cit. 



70 SYPHILIS OF THE INNOCENT 

Still 1 found that 10 per cent of his cases of hereditary 
syphilis showed affected brains. In 148 consecutive cases of 
congenital syphilitics there were six congenital idiots and 
four cases of mental decline in childhood. Thus 7 per cent of 
his group of syphilitic children showed mental defects. 

Dr. Lucas 2 made an intensive study of 60 cases of congenital 
syphilis at the Children's Hospital in Boston. He followed 
these children for a period of several years to see what became 
of them. He found that one third had died, that one third 
were apparently normal, and that one third were deficient in 
their school work. He concludes that this indicates that 
syphilis is one of the sources of backwardness in school 
children. 

The above figures merely show that syphilis and feeble- 
mindedness occur in the same child and that syphilitics have 
feeble-minded children. The exact etiological relation on a 
percentage basis has not yet been established. 

Syphilis as Cause of Two Types of Feeble-mindedness. — i 

Two types of feeble-mindedness, however, may be considered 
as due to congenital syphilis: 

1. That type in which, because of syphilitic defect in the 
germ plasm, the brain is laid down poorly. The defect in this 
case is a defect in the development of the brain. 

2. That type in which the brain has been properly laid down 
in the embryonic state but becomes destroyed either during 
the intrauterine life or within the first few years of life. 

Hydrocephalic idiocy has been thought to be caused by 
congenital syphilis in a high percentage of the cases. This is 
probably not true. Eecent studies by us and others have 
failed to detect the presence of syphilis in cases of hydro- 
cephalic idiocy, except in rare instances. Congenital syphilis 
has been found by us to be more frequent in cases of micro- 
cephalus than in hydrocephalus. 

1 Pusey, op. cit., p. 66, quotes Still. 

2 Lucas, W. P., Contributions to the Neurology of the Child. II. Note on 
the Mortality and Proportion of Backward Children in Cases of Congenital 
Syphilis Followed Subsequent to Hospital Treatment, Boston Medical end 
Surgical Journal, Feb. 29, 1912, Aug. 29. 1912, Sept. 4, 1913. 



THE CHILD 71 

Precocious Congenital Syphilitics. — In contradistinction to 
feeble-mindedness caused by syphilis, occasional syphilitic 
children are unusually precocious, and have a high mental 
rating. This does not indicate that the syphilitic heredity is 
an asset nor that it is the cause of precociousness, but merely 
that the syphilis had no effect on the particular child's 
mentality. 

Case 47. Wendall Morris was an orphan who showed certain stig- 
mata of congenital syphilis and a positive Wassermann reaction. 
When first seen by ns he was 8 years of age and was spoken of as 
1 ' nervous, ' ' that is, he was very active and it was difficult for him to 
keep still. He was found to be a very bright, alert, and attractive 
child. He was ahead of his years in school and a ps3 r chometric exami- 
nation showed that he had a mental age of over ten years. He was 
examined again when he was 10 years and 8 months old. At this 
time the psychometric rating was fourteen years. A third examina- 
tion was made when he was 14 years and 8 months old and on this 
occasion he rated over 17. His school record each time corresponded 
with the psychometric tests in that he was a couple of years further 
advanced than the average child of his age. This boy who had con- 
genital syphilis was the opposite of feeble-minded, that is, he was 
precocious. 

Involvement of Central Nervous System. — The nervous sys- 
tem is involved in congenital syphilis in the same way as in 
the acquired form of the disease and certainly with no less 
frequency. Jeans 1 examined 214 syphilitic children ranging 
in age from infancy to fourteen years, basing his diagnosis 
of involvement of the central nervous system upon the patho- 
logical findings in the cerebrospinal fluid. He divided his 
cases into two groups : the first group containing the children 
under two years of age ; the second, those from two to fourteen 
years : To quote Jeans : 

. . . it is seen, then, that the nervous system was involved in 
40 per cent of syphilitic infants, 31 per cent of older children having 
active infection and 20 per cent of older children having latent infec- 
tion. Of the entire group of 214 infants and children, the nervous 

l Jeans, Cerebrospinal Involvement in Hereditary Syphilis, American Journal 
of Diseases of Children, vol. 18, Sept., 1919, pp. 173-178. 



72 SYPHILIS OF THE INNOCENT 

system was involved in 70, or 32.7 per cent. Of those having positive 
cerebrospinal fluids slightly more than one third of the infants and 
slightly more than two thirds of the older children had clinical mani- 
festations of neurosyphilis at the time of observation. 

One may conclude from Jeans' report that by doing early 
lumbar punctures one can make a diagnosis of central nervous 
system involvement prior to the appearance of symptoms 
depending upon destructive lesions. Kingery, 1 in a study of 
the spinal fluids of 52 cases of congenital syphilis, found that 
28.8 per cent showed some deviation from the normal. 

According to a study made by Veeder 2 in a series of 100 
late cases of congenital syphilis, the nervous system was 
involved in 47 and, of these, at least 14 had cerebrospinal 
syphilis in one form or another. 

Table 13. Types op Involvement in 100 Cases op Congenital 

Syphilis (Veeder) 

Bones Central Nervous System 

Periostitis tibia 4 Mental deficiency 23 

Periostitis skull * . . . 1 Cerebrospinal syphilis , . 14 

Osteomyelitis 1 Hemiplegia 6 

Epilepsy 5 

Joints Spastic paraplegia 4 

Acute arthritis knee 8 Chorea 2 

Acute arthritis ankle 1 Hydrocephalus 2 

Skin Miscellaneous Conditions 

Macular eruption 1 Ozena 1 

Condyloma ani 3 Enlarged spleen (only symptom) . 1 

Gummata 3 Torticollis 1 

Alopecia 3 Aortitis 1 

Obscure abdominal pain 1 

Eye Obscure pain in legs 2 

Interstitial keratitis 24 Endarteritis obliterans 1 

Choroiditis 1 Paroxysmal hemoglobinuria 1 

Raynauds ' Disease 1 

Ulcerations Hutchinson 's teeth 4 

Nasal 2 

Laryngeal 1 

Pharyngeal 1 

1 Kingery, L. B., A Study of the Spinal Fluid in Fifty-two Cases of Con- 
genital Syphilis, Journal of the American Medical Association, vol. 76, Jan. 1, 
1921, p. 12. 

2 Veeder, op. cit. 



THE CHILD 73 

The most important of the inflammatory conditions of the 
nervous system are juvenile paresis, cerebrospinal syphilis, 
juvenile tabes, and certain cases of epilepsy. As is true in 
acquired syphilis, so in congenital syphilis the severest type 
of reaction is that of paresis. Juvenile paresis was first 
described by Clouston in 1877. While not a condition that is 
met very frequently, it is by no means rare. The symptoms 
are similar to those of the acquired form. A child who may 
have appeared entirely well develops slowly increasing mental 
symptoms some time before or at the adolescent period. The 
patient deteriorates and finally dies several years after the 
beginning of the symptoms. Prognosis is entirely hopeless 
as far as we can tell to-day. Juvenile paresis is a progressive 
dementing psychosis leading to death. Cases of juvenile 
paresis very frequently develop in children who show no 
marked stigmata of congenital syphilis and who have had no 
symptoms prior to the onset of those of the nervous system. 
Juvenile paresis tends to cut short the lives of its victims at 
a period when they are just coming into their full heritage. 
The average age of the onset is about 14 years, but cases have 
been described in the literature as young as 8 years and as 
old as 23. Cases of juvenile paresis which begin quite early 
in life are frequently erroneously diagnosed as cases of feeble- 
mindedness. 

Case 48. John Friedreich was a child of syphilitic parents who 
was recognized as a congenital syphilitic shortly after birth and was 
given antisyphilitic treatment almost immediately. He did not have 
a normal mental development and was considered feeble-minded. He 
had been slow in learning to walk and talk. At the age of 5 he began 
to show difficulty in walking. When seen at the clinic at the age of 
7 he had deteriorated considerably. He was quite deaf, apparently 
was unable to talk coherently, walked with an ungainly gait, was 
subject to fainting spells, and was exceedingly difficult to care for. 
The examination showed symptoms of nervous system involvement, 
namely, deafness, Argyll-Kobertson pupils, and a positive Wasser- 
mann reaction in the blood and spinal fluid. This case is of im- 
portance in indicating that cases treated from the very first weeks of 
life may go on without improvement and develop paresis. 

Case 49. The Bradford family is indeed an unusual one in that 
there were two children both of whom had juvenile paresis. The 



74 SYPHILIS OF THE INNOCENT 

family consisted of the father and mother and two girls 16 and 14 
years, respectively, at the time of their first appearance at our clinic. 
The older girl had been quite well until the age of 12 when she suf- 
fered a shock which left her paralyzed. Esther, the younger, had 
been perfectly healthy in her childhood and was considered a bright 
and active student until she reached the fourth grade in school. 
Then, at the age of 10, she began to show evidence of deterioration. 
She complained of headaches, trouble with her stomach, and drowsi- 
ness. Next difficulty with speech, gait, and coordination appeared. 
She deteriorated very rapidly and when seen at 14 was greatly de- 
mented. The whole picture including the laboratory tests of the 
blood and spinal fluid led to the diagnosis of juvenile paresis, with a 
prognosis of death in a period of months or not more than a few 
years. The older sister also had a positive blood and spinal fluid. 
The Wassermann reaction on the mother was positive and that of the 
father was negative. It may be mentioned that neither child was 
correctly diagnosed until the ages of 16 and 14 respectively. Juvenile 
paresis is a condition which is very frequently unrecognized until 
the very late stages. 

Case 50. Philip Griffin had a variegated history. Always difficult 
to manage, he had been in a reformatory on several occasions and 
was finally sent to the hospital at the age of 24 because of threatening 
his sister with a loaded revolver. The examination disclosed teeth 
that were rather characteristic of congenital syphilis, a real dementia 
was present, and he had unequal, poorly reacting pupils. His spinal 
fluid gave all the signs of general paresis and he continued to dete- 
riorate quite rapidly. It is interesting to note that this patient had 
a negative Wassermann reaction in the blood, emphasizing the point 
that in cases of congenital syphilis one must not rely too much on a 
negative blood test. 

Cerebrospinal Syphilis. — Less serious as to prognosis are 
the eases of syphilitic involvement which are similar to those 
known in the acquired form as cerebrospinal syphilis. These 
cases show^ a variety of symptoms, including paralysis of the 
cranial nerves and conditions such as paraplegia, hemiplegia, 
or merely meningitis. 

Case 51. Jo Weinberg was a young man of inferior mentality but he 
was sufficiently well endowed to get along in a labor battalion in the 
army. Shortly after his discharge he developed a hemiplegia. Ex- 
amination showed that he was a congenital syphilitic with a positive 



THE CHILD 75 

Wasserniann reaction in the blood and spinal fluid. His case was of 
the type of cerebrospinal syphilis and under antisyphilitic treatment 
he made a very good recovery from this hemiplegia and regained his 
former status. 

Juvenile Tabes. — Juvenile tabes or locomotor ataxia is 
quite rare and much less frequent than juvenile paresis or 
other forms of congenital neurosyphilis. The signs and symp- 
toms are similar to those of tabes resulting from acquired 
syphilis. 

Epilepsy. — The relation of congenital syphilis to epilepsy 
has been given a great deal of consideration by investigators. 
The situation resembles that of congenital syphilis and 
feeble-mindedness. 

Convulsions may occur in any case of inflammatory involve- 
ment of the nervous system of syphilitic origin. Cases of 
juvenile paresis, cerebrospinal syphilis, etc., in which there is 
active inflammation, are somewhat different from the cases of 
syphilitic epilepsy in which there is no evidence of an active 
syphilitic inflammation of the brain or meninges. One has to 
differentiate between epilepsy occurring in the congenital 
syphilitic and epilepsy which is caused by syphilis. It is 
possible that the epilepsy may have an origin not at all related 
to the syphilis. 

Case 52. The case of Peter Flynn brings up the question of the 
relationship between epilepsy and congenital syphilis. The family 
consists of the father and mother and six children of whom Peter is 
the oldest. The mother and father and four oldest children all have 
positive Wassermann reactions while the two youngest have negative 
Wassermann reactions. Peter had a convulsion at the age of 2 and 
then no more until the age of 15 when they occurred with great fre- 
quency. Aside from the congenital syphilis there is no suggestion of 
any cause for the epilepsy. The heredity is quite negative as far as 
epilepsy or like conditions are concerned. 

Case 53. Laurence Balch was subject to epileptic attacks. Ex- 
amination showed that he had a positive Wassermann reaction. Al- 
though Laurence was 20 years of age he gave no history of having 
acquired syphilis, his father was syphilitic and there was a basis for 



76 SYPHILIS OF THE INNOCENT 

the assumption that he was a congenital syphilitic. However, though 
this be true, it does not follow that the epilepsy was the result of con- 
genital syphilis. This becomes particularly pertinent when it is 
found that the mother was herself epileptic. It seems quite probable, 
therefore, that Laurence's epilepsy could be traced to the epilepsy 
in his mother rather than to syphilis. 

A Wassermann survey of Craig Colony, New York, an insti- 
tution for epileptics, made by Shanahan, Shaw, and Mnnson, 
disclosed that among 4100 epileptics, most of whom were 
adults, less than 2 per cent gave a positive Wassermann test. 
At the Monson State Hospital in Massachusetts, of 535 epilep- 
tics a positive Wassermann was obtained in 3.34 per cent. 
However, the figures are considerably different when youth- 
ful epileptics are considered as in contrast to the figures for 
the adult epileptic. At the Monson State Hospital, Dr. M. B. 
Hodskin found that of 104 children with epilepsy, all of whom 
were under 15 years of age, 21 per cent gave positive Wasser- 
manns. Jeans of St. Louis found that 20 per cent of his cases 
of epilepsy were congenital syphilitics. 

The wide variation between the percentages of Wassermann 
positive cases among the adult and youthful epileptics 
demands explanation. There are two hypotheses at hand: 
one, that in the cases where epilepsy is caused by congenital 
syphilis, the epilepsy comes on early in life, and that epilepsy 
occurring somewhat later is less frequently of congenital 
syphilitic origin, or two, that many of the adult epileptics 
who gave negative Wassermann reactions are congenital 
syphilitics, who earlier in life did show positive Wassermann 
tests, but as they matured this finding became negative. At 
any rate, the high frequency of Wassermann reactions in 
youthful epileptics is highly suggestive that there may be a 
relationship between epilepsy and congenital syphilis. How- 
ever, the present state of knowledge concerning this subject 
does not allow us to draw any definite conclusions. For the 
present it must be left an open question which needs 
considerable further study. 

Relation of Other Psychopathies to Parental Syphilis — 
Instability. — In addition to the above effects of syphilis on 



THE CHILD 77 

the child, one must consider several more mooted points. If 
a child of syphilitic parents has none of the above mentioned 
forms of syphilis is that child to be considered healthy? 
Stated differently, if a child has other difficulties than those 
given above, are these difficulties caused by the parental 
syphilis! From this point of view it is pertinent to think of 
general weakness, emotional disorders and the psychoneu- 
roses, psychoses, and character defects. Some syphilologists, 
for instance Graves of St, Louis, and Browning and McKenzie 
of Glasgow, believe that the offspring of syphilitic parents are 
apt to show conditions of poor stability, and would suggest 
that even in the absence of definite symptoms of active syphilis 
such children be treated by antisyphilitic drugs. One not 
infrequently sees children of syphilitic parents who are ner- 
vous, fidgety, and who do not thrive any too well. Whether 
one can relate these conditions to the parental syphilis is a 
question that cannot be easily determined. 

Case 54. Mrs. White was informed that she had syphilis when she 
was 23 years of age. However, she neglected to take treatment. She 
bore five children. According to the history the oldest had poliomye- 
litis at 2 years. The second child at the age of 19 was unable to walk 
in a normal manner. He was said to be sullen, morose and unwilling 
to work. The third boy at the age of 18 was weak and sickly. The 
fourth child had been under antisyphilitic treatment for five years 
but had not thriven. At the time of our acquaintance with her she 
was about 15 years of age. She was nervous, excited, moody, easily 
depressed, and given to fits of temper. The fifth child died im- 
mediately after birth. The relationship of syphilis in the parents and 
psychoneuroses in the children is interesting. 

Tarnowsky 1 reports on three families born of syphilitic par- 
ents. There were 22 births. There was only one healthy 
adult man, Of 13 who survived some years, 8, having mental 
or physical defects, were incapable of self-support. Five were 
nervous and weak. Syphilis was given as the sole cause of 
the weakness of the offspring. 

l Bulkier, L. D., Syphilis in the Innocent, New York, Bailey and Fairckild, 
p. 198 quotes Tarnowsky, Prostitution und Aoolitionismns, Hamburg, 1890. 



78 SYPHILIS OF THE INNOCENT 

Hysteria. — One undoubtedly finds a large number of cases 
of hysteria and other nervous conditions arising in the 
offspring of syphilitics. Nonne, 1 for instance, says: 

. . . in such cases the so-called ''nervousness" takes a hysteric 
or hysteriform character. This I have seen more than once in develop- 
ing girls and women, whose fathers had died of paresis; the patients 
at times had a positive, at times a negative Wassermann reaction in 
the blood. 

Freud 2 says in regard to the relation of syphilitic heredity 
to hysteria: 

. . . in more than one half of the severe cases of hysteria, com- 
pulsion neuroses, etc., which I have treated by psychotherapy, I have 
succeeded in positively demonstrating that their fathers had gone 
through an attack of syphilis before marriage. They have either 
suffered from tabes or paresis, or there was a general history of lues. 
I expressly add that the children who were later neurotic showed 
absolutely no signs of hereditary lues, so that the abnormal sexual 
constitution was to be considered as the last offshoot of the luetic 
heredity. 

Case 55. Pauline Thomson came under consideration at the age 
of 20 when she was diagnosed as having a compulsion neurosis of 
sufficient severity to necessitate hospital treatment. The family his- 
tory showed that the father had been divorced some ten years before 
Pauline's breakdown. From the history it seems that he was a rather 
inferior individual. The mother was suffering from tabes. The 
family consisted of six children, the oldest, a girl of 27, was married 
and well. The second child died at 2 years of scarlet fever. The 
third was a boy of 22 who was living and well. The fourth was the 
patient. The fifth child was a girl who died at two years of scarlet 
fever and the sixth a boy of 12 years who was well. It can be seen 
at once that it is quite impossible to associate Pauline 's neurotic con- 
dition with the syphilis of the mother. As plausible a possibility would 
be to blame her inferior constitution on her father's alcoholism or on 
his general mental and moral deficiencies. 

1 Noime, op. cit., p. 713. 

2 Freud, Three Contributions to the Sexual Theory (Brill's translation), Wash- 
ington, Nervous and Mental Disease Publishing Co., 1910, p. 80. 



THE CHILD 79 

Psychoses. — The German authors especially have been inter- 
ested in the question of psychoses in the children of syphilitics. 
Nonne 1 says "it has been astonishing to me to see in recent 
years how relatively frequently one finds lues in the ascend- 
ants of youthful individuals with dementia praecox. ' ' Pilcz, 2 
in a study of 416 cases of dementia praecox, found tabes in the 
parents of 5 per cent, while in manic depressive insanity he 
found that only 0.6 per cent of the parents had tabes. In the 
parents of 44 patients with hebephrenic dementia praecox he 
found general paresis occurring 23 times. In the parents of 
27 catatonic dementia praecox patients he found five instances 
of general paresis. It has been our experience that there is 
no close relationship between psychoses and syphilis in the 
progenitors. Although it is a possibility it does not seem to 
be sufficiently established at the present time to merit much 
consideration. With two conditions as frequent as syphilis 
and the various psychoses, it is, of course, inevitable that there 
should be cases of psychoses developing in the offspring of 
the syphilitic, but it is quite another matter to establish the 
fact that there is a relationship between the parental syphilis 
and the psychoses of the offspring. The following case is one 
in which the arguments may be used either way: 

Case 56. Lucien Cattrell contracted syphilis and infected his wife 
who later developed general paresis. The children of this marriage 
were free from any definite symptoms of congenital syphilis and all 
had negative Wassermann reactions. At the age of 16 the oldest 
child developed a psychosis diagnosed as manic depressive insanity. 
As has been stated, he was free from signs or symptoms of congenital 
syphilis. 

Character Defects and Delinquencies. — What has been 
stated above about the psychoneuroses and psychoses holds 
also for various character defects, delinquencies, and psycho- 
pathic inferiorities. In the literature one finds many refer- 
ences to their relationship to syphilis in the progenitors. 
Thus, Hochsinger says "there can be no doubt that the 'moral 
insanity ' of the descendants of a luetic father depended upon 

i Nonne, op. cit., p. 776. 

2 Kraepelin, E., Psychiatrie, eighth edition, Leipzig, vol. iii, 1913, p. 921 quotes 
Pilcz. 



80 SYPHILIS OF THE INNOCENT 

a psychic inferiority of a congenital nature which was related 
to the lues of the ascendant. ' ' Nonne, Fournier, and Barthel- 
emy agreed with this doctrine. Their statements are based 
upon their impressions, rather than upon any definite 
statistical data which can be evaluated. 

Haines, 1 in attempting to establish a causal relationship 
between syphilis and delinquency, studied 365 delinquent chil- 
dren. He found that 20.8 per cent of this group gave positive 
Wassermann reactions. 

Bazeley and Anderson 2 made a study of our cases bearing 
on the relationship of congenital syphilis to delinquency from 
a slightly different point of view. They analyzed the forms 
of difficulties of two groups of 60 delinquents. In the first 
group they studied 60 delinquents who had congenital syphilis 
comparing them to the second group which consisted of 60 
non-syphilitic delinquents. To quote them: 

The delinquencies were then treated under three groups — indi- 
vidual, property, and society. Individual delinquencies were con- 
sidered to be those of truancy, stubbornness, incorrigibility, lying and 
sex. The property delinquencies were considered to be larceny, 
destruction, setting fires, and breaking and entering. The society 
delinquencies were considered to be disorderly conduct, contentious- 
ness, fighting, carrying concealed weapons, assault with intent to do 
bodily harm, and minor offenses. The results of this treatment are 
represented in the following table: 

Table 14. Delinquencies 

The three types: Syphilitica Non-syphilitics 

Individual. . 32 21 

Property 13 15 

Society 3 3 

Plural delinquencies in one individual 

None 24 32 

One only 18 18 

Two 8 3 

Three 7 4 

Four 3 2 

Five 1 

60 60 

1 Haines, T. H., Incidence of Syphilis Among Juvenile Delinquents, Journal 
of the American Medical Association, vol. 66, no. 2, 1916, p. 102. 

2 Bazeley and Anderson, Mental Features of Congenital Syphilitica, Boston 
Medical and Surgical Journal, vol. 173, no. 26, Dec. 23, 1915, pp. 952-956. 



THE CHILD 81 

The subject of the delinquency of the congenital syphilitic 
is one which cannot be readily resolved. There is certainly 
an indication that it is worth while to consider the possibility 
of congenital syphilis in all juvenile delinquents. If syphilis 
is found, the treatment of the case will include antisyphilitic 
therapy along with the social means of handling delinquency. 

Case 57. Merton Winship was the only child of a syphilitic mother. 
He showed a number of stigmata of congenital syphilis as well as a 
positive Wassermann reaction in the blood. He was wilful, destruc- 
tive, malicious, and unmanageable. He would not keep quiet at 
school and became a great problem because of his behavioristic diffi- 
culties. It was because of the difficulty of controlling him that he 
was brought to the hospital for examination. In this case it seems 
quite probable that congenital syphilis was in some way related to 
his restlessness and mischievousness. It may be added that during 
a period of several years' observation and antisyphilitic treatment 
there was a good deal of improvement in Merton. It was, of course, 
not possible to say how much depended upon training and the in- 
crease of stability with advancing years and how much was due to 
the antisyphilitic treatment. 

Case 58. Jean Lebovitz was also a delinquent congenital syphilitic. 
From the time she was first known to the clinic at the age of 9 to 
her present age of 14 she has shown a marked wanderlust. The police 
frequently brought her home after unexplained disappearances of 
several days. Treatment has been given off and on for five years. 
The delinquencies still continue and we cannot tell whether or not 
they have any relation to the syphilis. 

Transmission of Syphilis to Third Generation.— Substantial 
evidence is lacking to prove that syphilis is ever transmitted 
to the third generation. A great deal of study has been given 
to this subject, especially by Tarnowsky and the younger 
Fournier. A few cases have been reported indicating that 
the disease had been transmitted by a congenital syphilitic to 
the offspring but none of these cases have been accepted as 
free from error. It is always difficult to be sure that a non- 
congenitally syphilitic parent has not contracted syphilis 
and transmitted it to the offspring or that a congenital syphil- 
itic has not had a super-infection and thus transmitted syphilis 
to the second generation rather than to the third. It may be 



82 SYPHILIS OF THE INNOCENT 

stated that while there is some divergence of opinion, the 
general tendency is to believe that syphilis is not transmis- 
sible beyond the second generation. This means, of course, 
that a congenital syphilitic is probably never contagious by 
the time the age of marriage has been reached. Thus, a male 
congenital syphilitic would not infect his wife nor, through 
her, their offspring. Likewise, a congenitally syphilitic 
woman and a non-syphilitic husband would not give birth to 
a syphilitic child. 

Case 59. Katherine Burke was 23 years of age when she arrived 
at the clinic to which she had been referred by the ophthalmologist 
because of interstitial keratitis. Her Wassermann reaction was posi- 
tive and a diagnosis of congenital syphilis was made. This patient 
was a subject of the late manifestations of congenital syphilis 
(syphilis hereditaria tarda). She was married and had one child; 
there had been no accidents to pregnancies. Her husband showed no 
signs or symptoms of syphilis and the child was free from the disease. 

Case 60. Frederick Waters was a congenital syphilitic who had 
been married for three years. His wife had had two pregnancies 
resulting in normal, healthy children and she herself was free from 
any signs or symptoms of syphilis. Thus, this young man who de- 
veloped active symptoms of congenital syphilis was not infective to 
his wife and did not transmit the disease to the third generation. 

Case 61. In the case of Michael "Wald's sister the diagnosis of con- 
genital syphilis was made on the basis of a positive Wassermann reac- 
tion and the family history. The patient sought medical advice be- 
cause of a gynecological disorder. Her father and mother were found 
to be syphilitic and her brother had juvenile paresis. The patient 
was married and although she had had several miscarriages she gave 
birth to two normal healthy children. In this case again we have an 
instance of the marriage of a congenital syphilitic without infection 
of the husband and resulting in the birth of nonsyphilitic children. 

It has been stated that while the offspring of a congenital 
syphilitic may not show evidence of an active syphilitic infec- 
tion, they may present abnormalities dependent upon the con- 
genital syphilis of the parent. Thus Fournier believes that 
the third generation may show various dystrophies, peculiar- 
ities, or abnormalities of the anatomical structure, nervous- 



THE CHILD 83 

ness, and weakness. Fournier 1 reports the following case 
from Tarnowsky's clinic: A healthy woman with a heredo- 
syphilitic husband had eleven pregnancies, of which eight 
were stillbirths. Of the three living children one w T as a 
hystero-epileptic, another tuberculous, and the third had an 
exophthalmic goiter. Stokes 2 says "it is generally conceded 
that a tendency to constitutional inferiority appears in the 
children of parents who have severe forms of hereditary 
syphilis. Those who have hereditary syphilis in mild form, 
however, may, if efficiently treated, give birth to healthy 
children. ' ' 

Methods of Diagnosis of Congenital Syphilis. — Having seen 
the protean nature of the symptoms of congenital syphilis, it 
is proper that attention should be given to the diagnosis of 
congenital syphilis. For this purpose it is necessary to con- 
sider (1) the family history, (2) the medical history of the 
child, (3) the physical examination of the child, (4) the 
examination of other members of the family for evidence of 
syphilis. 

Family History. — 1. Under the family history, one searches 
for any evidence of syphilis in the parents or brothers and 
sisters of the patient. The parents are carefully questioned 
for any history of symptoms of syphilis in themselves. This 
includes the symptoms of the primary, secondary, and late 
stages of the disorder, as well as a history of the pregnancies. 
As has been seen, a series of abortions, miscarriages, and still- 
births is suggestive of syphilis if no other definite cause for 
such accidents to pregnancies is discovered. The history of 
the brothers and sisters of the child under investigation is 
gone into to learn if they have had any symptoms that are 
suggestive of congenital syphilis. 

1 Fournier, A., Treatment and Prophylaxis of Syphilis, English translation of 
the second edition, revised and enlarged by C. F. Marshall. American edition, 
revised and corrected "with an appendix by George Mackee, New York, Rebman, 
p. 478. 

2 Stokes. J. H., To-day's World Problem in Disease Prevention, issued by the 
U. S. Public Health Service, Treasury Department, Washington, D. C, p. 85. 



84 SYPHILIS OF THE INNOCEXT 

Medical History of Child. — 2. The history of the patient is 
considered in detail to see if there occurred any of the symp- 
toms which are highly suggestive or almost pathognomonic 
of congenital syphilis. The more important early symptoms 
are snuffles, skin disorders of early infancy, and marasmus; 
the later ones interstitial keratitis, nerve deafness, hydrops 
articulorum and the like. 

Examination of Child. — 3. The examination of the child is, 
of course, of the greatest importance. One must first look 
for the stigmata of congenital syphilis, which include such 
important factors as the Hutchinsoniaii triad, sabre tibiae, 
Olympic forehead, and scars of old rhagades about the mouth. 
Then evidence of acute syphilitic manifestations, such as bone 
changes, effusion of the knees, syphilitic changes in the 
choroid of the eyes, skin lesions, etc., must be sought. Finally, 
the laboratory investigation has become a distinct factor in 
the determination of congenital as well as acquired syphilis. 
The Wassermann reaction of the blood is probably the test of 
most importance. The luetin test is also of value, although 
not so well standardized as the Wassermann test. The 
examination of the cerebrospinal fluid is also of great value. 

Examination of Family. — 4. The examination of the parents 
and siblings of the patient is another essential part of the 
investigation. Here the same process is brought into play as 
in the examination of the patient. 

Evaluation of the Four Methods of Diagnosis. — Without all 
these factors it is impossible to feel that one is justified in 
giving a non-syphilitic diagnosis to a suspicious child. Of 
course, in obvious cases of congenital syphilis it is not neces- 
sary to go through all of this procedure for the purpose of 
making a diagnosis on the individual, but from the standpoint 
of real syphilology and of the service that should be rendered 
to every family such an examination is always indicated. 
The evaluation of the various factors mentioned for the diag- 
nosis of congenital syphilis calls for the highest clinical 
acumen and knowledge. If one finds evidence from the his- 



THE CHILD 



85 



tory and the examination of the parents that they have had 
syphilis, although highly suggestive it does not follow that 
the child is syphilitic. On the other hand, the failure to dis- 
cover any evidence of syphilis in the parents does not preclude 
the possibility of the child's being congenitally syphilitic. 
Similarly, the history of the child may indicate early sugges- 
tive symptoms which may have been of other etiology than 
syphilis. Or, in spite of the absence of any such early symp- 
toms, the child may be a congenital syphilitic. Again, in the 
examination, stigmata may or may not be present. When 
present they are, of course, highly important, but it is very 
easy for a tyro to consider the results of rickets as stigmata 
of congenital syphilis. 

Wassermann Reaction — Its Interpretation. — The Wasser- 
mann reaction offers a great deal of aid to diagnosis, but again 
its interpretation is something that must presuppose a good 
deal of knowledge. A consistently positive Wassermann 
reaction may be considered as definite evidence of syphilis. 
This does not mean, however, that the syphilis is congenital, 
as it may have been acquired early in life. A negative Was- 
sermann reaction is quite frequent in cases of congenital 
syphilis, especially in the first weeks of life. This is particu- 
larly true in cases that have had early treatment, yet often 
when the Wassermann reaction is negative the child may be 
suffering from the activity of the treponema. There is con- 
siderable evidence that the Wassermann reaction in cases of 
congenital syphilis tends to become negative as time goes on. 
If one investigates a group of congenital syphilitics during 
the period of adolescence, the test will be negative in a fair 
percentage of the cases. 

There are besides many possibilities of error in the perform- 
ance of the test. The more sensitive the antigen used, the 
higher the percentage of cases of syphilis which will give a 
positive Wassermann reaction, but in addition to picking 
close to 100 per cent of the cases of syphilis, a certain number 
of non-syphilitic cases will unquestionably give a positive 
Wassermann reaction. An antigen which is weaker and 
which avoids to a large extent the production of positive reac- 



86 SYPHILIS OF THE INNOCENT 

tions in cases that are not syphilitic, will also miss many 
syphilitic ones. At the present time there is no method that 
will avoid this difficulty. In addition, errors in the technique 
may lead to erroneous results. It is, therefore, obvious that 
one must not depend upon the Wassermann test for a diag- 
nosis of congenital syphilis. It is an important aid when 
properly evaluated. 

An examination of the spinal fluid is often indicated in cases 
suspected of congenital syphilis. This examination will throw 
light upon the question of involvement of the central nervous 
system, and at times, when the Wassermann reaction is nega- 
tive in the blood, it will be found positive in the cerebrospinal 
fluid. 

In some cases all the four methods of diagnosing congenital 
syphilis will yield positive results, that is, upon examination 
of the child stigmata as well as active symptoms and a positive 
Wassermann reaction will be found; the medical history of 
the child will disclose previous suggestive syphilitic symp- 
toms; the family history will include syphilitic symptoms 
with a history of accidents to pregnancies; and finally, the 
parents and siblings upon investigation will give evidence 
of syphilis. 

All Four Factors Not Always Present in Given Case. — It is 

more frequent for only one or a combination of several of the 
four factors to be present in a given case. Thus, without 
a history of syphilis in the parents, their examination may 
disclose evidence of syphilis. A syphilitic offspring may or 
may not show marked stigmata or a history of early symp- 
toms. The patient under consideration may have been the 
first child and the siblings be quite free of any signs or 
symptoms of syphilis. 

Case 62. On examination, Elizabeth Stuart proved to be a con- 
genital syphilitic. She had teeth Hutchinsonian in type and deficient 
in enamel, irregular pupils, scars of interstitial keratitis, and was 
underdeveloped. Her Wassermann reaction was positive. 

Case 63. An examination of Robert Clairmont showed he had a 
positive Wassermann reaction with Hutchinsonian teeth and slight 
scars about the mouth. The history showed that he had had a skin 



THE CHILD 



87 



eruption after birth with sores on his mouth. The examination, con- 
firmed by the history of the child, allowed a diagnosis of congenital 
syphilis. In addition, there was a history of three stillbirths before 
Robert's birth. 

Case 64. Annette Baroni was brought to the clinic with a question 
of mental deficiency. She had just borne an illegitimate child. On 
examination she was found to be syphilitic but there was not enough 
to substantiate the diagnosis of congenital syphilis. However, family 
examination revealed that the mother was syphilitic as were the two 
children born after the patient, The examination of the relatives in 
this case helped to establish the diagnosis. 

Case 65. William Bice at the age of 5 showed no symptoms or 
stigmata of congenital syphilis, nor was there any suggestive personal 
history. He was examined because he was the son of a general 
paretic and had a positive Wassermann. An examination of the 
mother showed that she was syphilitic. The two oldest children were 
non-syphilitic. There were a death and a miscarriage after "William's 
birth. The history of parental syphilis here confirmed the diagnosis 
of congenital syphilis. 

Diagnosis of Congenital or Acquired Syphilis in a Child. — 

After having made the diagnosis of syphilis on a child the 
question may arise whether the syphilis is congenital or 
acquired. It is often quite difficult to decide the source of 
infection. A child born of normal healthy parents may 
develop syphilis at a very early age. Very frequently the 
infection is not recognized at that time : so that the history 
does not throw light upon its origin. In dealing with children 
at the age of puberty and adolescence one has to consider the 
possibility of syphilis acquired by extragenital or genital 
methods as w^ell as congenital syphilis. The assumption in a 
young person ahvays is that the syphilis is congenital, but 
upon careful investigation this assumption may be proved 
incorrect. 

Case 66. Rachael Miller. An infant was brought to the hospital 
at the age of seven weeks with a well-developed chancre in the region 
of the eyebrow. It was not known how the child acquired syphilis 
though presumably from some relative or friend who had kissed the 
infant. It is very easy to imagine how such a case could escape a 



88 SYPHILIS OF THE INNOCENT 

proper diagnosis and a few years later the obvious assumption would 
be that the case was one of congenital syphilis without signs. 

Case 67. Harold Maguire was brought to the hospital at the age 
of 12 because of convulsions. Examination disclosed the fact that he 
was suffering from a syphilitic involvement of the nervous system. 
The history obtained from the family physician indicated that the 
father had acquired syphilis when Harold was a few weeks old and 
had infected the mother and son. The boy had acquired syphilis at 
the age of a few weeks and was not a congenital syphilitic. 

Ca<se 68. Ronald Neilson came to the hospital when he was 19 years 
of age with well marked symptoms of general paresis which had been 
developing for over a year. Paresis is a condition which usually 
develops from six to fifteen years after the primary infection, there- 
fore, to have accepted the idea that Ronald had general paresis from 
acquired syphilis would have meant that he had acquired it when 
not older than thirteen or fourteen years of age. The history showed 
that he had been a boy of exemplary habits, a fine type of youth. It 
did not seem probable, therefore, that he acquired syphilis through 
any fault of his own, and the assumption was that the case was one 
of juvenile paresis. The family history, however, was negative so 
far as we could learn. There had been no accidents to pregnancies. 
Ronald was the fourth child, the other children were apparently 
healthy. The mother and father disclaimed any knowledge of syphilis, 
showed no symptoms and the Wassermann reaction was negative. 
Two older and one younger brother were examined and were free from 
any evidence of syphilis including the Wassermann reaction. It was 
only after a period of some months that we succeeded in examining 
the oldest brother who gave "a history of having acquired syphilis 
about six or seven years prior and who had all the evidence of 
syphilitic infection. Just after the time that he had acquired syphilis 
he had been sleeping in the same bed as Ronald. This led to the con- 
clusion that Ronald had acquired syphilis from his older brother by 
chance contact. 

Case 69. Cora Meyer made the first visit to the hospital at the age 
of 21 because of conduct disorder. On examination it was discovered 
that she had a positive Wassermann reaction. She showed no definite 
stigmata of congenital syphilis. However, the mother also had a posi- 
tive Wassermann reaction. Was Cora a congenital syphilitic as might 
be possible because of the fact that her mother was syphilitic, or had 
she acquired syphilis? She had been exposed to venereal infection. 



THE CHILD 89 

On the other hand, her younger brother was seen about this time and 
had a newly acquired syphilis. It is not possible in this case to deter- 
mine whether or not Cora's syphilis was congenital or acquired. 

To investigate the family of the syphilitic child or adult is 
very much more important than to determine whether the 
syphilis is acquired or congenital or whether the individual 
under investigation is or is not syphilitic. Through investi- 
gation of the family of any syphilitic, many unsuspected cases 
of syphilis are brought to light. It is thereby possible to 
establish treatment at the time when it will do the most good. 

Congenital Syphilis Often Undiagnosed in Infancy. — Con- 
genital syphilis is often not discovered until fairly late in life. 
Dr. Lucas 1 made a study of cases of syphilis occurring in 
children under 18 years of age in an investigation of hospitals 
and clinics for a ten year period, from 1902 to 1911. He found 
885 cases of syphilis. Probably a few of these cases were ac- 
quired extragenitally or genitally. The large majority, how- 
ever, were congenital syphilitics. Fifty per cent of these cases 
occurred in children one year of age or under, and the remain- 
ing 50 per cent were scattered through the later years. That 
is, in 50 per cent the diagnosis was made early because of 
active symptoms in the first year of life. The other 50 per 
cent escaped diagnosis at this period and remained undiag- 
nosed for some time until some accidental symptom or another 
disease brought them under observation. 

l Lucas, W. P., Study for Massachusetts Society for Sex Education. Un- 
published. 



90 



SYPHILIS OF THE INNOCENT 



Special Study of Incidence of Congenital Syphilis in a Group of 
Institutions, 1902-1911, by Ages of Children x 



Number 

OF CASES 



•10U 
AC\C\ 


~T 


































350 
300 
250 
200 








































































\ 




































\ 








































































150 

100 






































1 


































50 

E IN 







































YEARS 



I 



Children's Hospital 
Infant 's Hospital 
Mass. General Hospital 
Boston City Hospital 
N. E. Hospital for 
Children 

i 885 cases of syphilis. 



Women and 



it? 



Homeopathic Hospital 

Boston Board of Health; vaginal and 

gonorrheal records. 
Boston Juvenile Court 
Mass. S. P. C. C. 



We have made a study of 49 syphilitic children occurring in 
the families of 33 syphilitic patients who entered our hospital. 
These children were brought into the hospital for an exam- 
ination on the ground that one parent had syphilis. The 
result of this study is given on the following page : 



THE CHILD 

Table 15 



91 





No. 


p. c. 




No. 


P. c. 


Total Children 

Total whose syphilis was discovered elsewhere 
Previous Wassermann reaction 
Previous treatment 
Total discovered by routine family examination 
Wassermann reaction 
Clinical signs 
Wassermann reaction and clinical signs 


"7 

7 

32 
2 


i4!3 

14.3 

65\3 
2.0 
4.1 


49 
14 

35 


100. 
28.6 

71*4 


Total Discovered by Routine Family Examination 
Number with serious unknown involvements 

Juvenile general paresis (treatment; not known if 

improved) 
Epilepsy (treatment ; not known if improved) 
Juvenile general paresis (too late to treat) 
Cerebrospinal syphilis (too late to treat) 
Number with other difficulties 

Iritis (improved under treatment) 
Retarded (improved under treatment) 
Feeble-mindedness, interstitial keratitis, blindness (too 

late to treat) 
Feeble-minded (treatment; not known if improved) 
Feeble-minded, spastic gait (treatment; not known if 

improved) 
Feeble-minded (not treated) 
Number with no other known difficulties 


1 
1 

1 
1 

' i 
1 

1 
1 

1 
1 


16\6 
16.6 

16.6 
16.6 

16.6 
16.6 


35 

4 

' 6 
25 


100. 
11.4 

17.2 

7i*i 


Total Discovered Elsewhere 
Number with other difficulties 

Iritis (improved under treatment) 

Interstitial keratitis (improved under treatment) 

Feeble-minded, deaf, failing eyesight, staggers (improved 

under treatment) 
Feeble-minded (treatment not given) 
Number with no other known difficulties 


' i 
1 

1 

1 


2o!" 
25. 

25. 
25. 


14 

4 

io 


100. 

28.6 

7i!i 


Total Mothers of all 49 Children 

Mothers dead 

Mothers not examined 

Mothers examined 
Mothers syphilitic 
Mothers non-syphilitic 
Mothers doubtful 


'26 
4 

1 


80 

16 

4 




33 
3 
5 

25 


100. 
9.1 

15.2 
75.7 



The above figures show : 

1. That the parents of 35 or 71.4 per cent of these 49 syphil- 
itic children were unaware that they had syphilis. Thus, 
unless these children had been examined as relatives of syphil- 
itics, they could not have been treated as early as was made 
possible by our discovery of the existence of syphilis. 

2. Of the 35 syphilitic children discovered by our family 
examination, 4 or 11.4 per cent had serious unrecognized 
involvements, such as nervous system syphilis. It was already 
too late to treat two of these cases, although the effort was 
made in one case without success. In the other two cases the 
effects of treatment were not known. An additional 6 or 17.2 
per cent had other difficulties, some definitely syphilitic in 
character, such as interstitial keratitis, blindness or deafness, 



92 SYPHILIS OF THE INNOCENT 

and others coincident with or caused by syphilis, such as 
feeble-mindedness. 

3. The median age at which syphilis was discovered by a 
routine family examination in the 35 cases found at this hos- 
pital was 9. In the majority of these cases syphilis was found 
by a Wassermann test. The median age of the eight children 
whose ages were known among those whose syphilis was dis- 
covered elsewhere was slightly less, being 7% years. The ages 
vary in these groups from 2 to 22 and 2 to 18, respectively. 
These ages show that a great many congenital syphilitics are 
not being found very early in life. Obviously, the earlier they 
are discovered, the earlier they will be treated and the more 
chance they have to avoid symptoms. 

The important lesson to be learned from this study is that 
many cases of congenital syphilis exist for years without 
being discovered, whereas an examination of the families of 
every syphilitic would bring much earlier recognition. Obvi- 
ously, if we had not brought these children to the clinic for 
examination on the ground that a parent had syphilis they 
would have escaped recognition for a still longer period. 

Social Difficulties Due to Congenital Syphilis — Contagious- 
ness of Syphilitic Infant. — There are many social maladjust- 
ments which may be ascribed to congenital syphilis. An 
infant with contagious lesions is a source of danger to others 
who must be protected from the patient during the period of 
infectivity. It should be possible, of course, to give the child 
institutional care if for any reason it is necessary to remove it 
from the home, yet there are still many institutions, including 
hospitals, which will not take syphilitic infants. Fortunately, 
the attitude in this regard has become saner, but there is still 
much room for improvement. 

Older Syphilitic Children Not Infectious. — While it is quite 
true that during the early period of life, when treatment has 
not been instituted, these children are a great danger to others, 
yet as the years go on this danger is lessened. It is hard for 
anyone who has contemplated the subject of syphilis without 
having learned all the facts to avoid being over-fearful in the 



THE CHILD 93 

presence of a person with congenital syphilis. Because of this 
fear on the part of the public the child is likely to suffer a 
considerable handicap if the fact that he has congenital 
syphilis becomes known. Yet, in late childhood and after, 
there is really very little danger of infection by congenital 
syphilitics even though they may be suffering from such active 
manifestations of the disease as interstitial keratitis, deaf- 
ness, bone lesions, paresis, etc. It is, therefore, safe for these 
children to mingle freely with others in school, in play, and 
in the pursuit of a career, and as has been seen, it is often 
possible for them to marry and have healthy children. 

Question of Adoption of Congenital Syphilitics. — The matter 
of adoption of a congenital syphilitic is one that frequently 
comes to one 's attention. A child who has been well treated, 
or who is past the first few years of life, might be adopted if 
one considered only contagiousness. It must be realized, 
however, in this connection that a congenital syphilitic is 
liable to the later disabling symptoms, and is on the whole 
a poor risk from the standpoint of health and development. 

Symptoms as a Handicap — Interstitial Keratitis and Inca- 
pacity. — The symptoms themselves are a great handicap to 
many children who are likely to be of inferior physical consti- 
tution, retarded in their early development, and, after having 
passed the early years, to be subject to the late manifestations 
of congenital syphilis. Consider, for instance, the handicap 
of interstitial keratitis. Every case of interstitial keratitis 
means a loss of much time from school work, during which 
time the patient is entirely incapacitated, while in many cases, 
permanent disability results. Thus Pusey 1 quotes Igles- 
heimer's work, which shows that of 152 cases of interstitial 
keratitis, 40 per cent were partly or completely disabled, and 
60 per cent recovered their eyesight. Almost one half of those 
who completely or partially lost their eyesight, lost their 
former capacity for earning a living. 

Case 70. In Elizabeth Stuart, interstitial keratitis began when she 
was 8 years of age. It was so severe that she became practically blind 

l Pusey, op. cit., p. 65, quotes Iglesheimer. 



94 SYPHILIS OF THE INNOCENT 

and as a result she had to leave school. Being an orphan in the care 
of the city she did not remain in her foster home but was sent to a 
hospital for intramural treatment. She remained seven months re- 
ceiving salvarsan treatment for syphilitic eye disease. During this 
entire period she could not go to school and thus lost a grade. Her 
eye trouble, however, cleared up so that she recovered practically nor- 
mal vision. 

In addition to interstitial keratitis there are a number of 
eye troubles which have already been mentioned as causing 
difficulty with vision and blindness, and which on the whole 
are even more serious in their results than interstitial keratitis. 

Syphilitic Deafness as Handicap. — The social handicap of 
syphilitic deafness, due to congenital syphilis, whether the 
deafness is partial or total, is enormous. When deafness 
occurs in infancy the result is frequently deaf -mutism. The 
amount of deafness from this cause is actually very high, and 
many of the inmates of institutions for the deaf are there 
because of congenital syphilis. No adequate surveys have 
been made either of the amount of deafness due to congenital 
syphilis or the number of inmates of institutions for the deaf 
who have syphilis, so that we are unable to offer any American 
figures as to the actual amount of deafness or deaf-mutism 
caused by congenital syphilis. 

Feeble-mindedness as Social Handicap. — Feeble-mindedness 
w 7 hen caused by syphilis or any other defect is an obvious 
social misfortune. Most feeble-minded persons cannot func- 
tion properly with the rest of the community and are led into 
crime, poverty, disease, etc., more frequently than their nor- 
mal brothers. If the premise is accepted that congenital 
syphilitics are more unstable, have more general weakness 
and liability to disease, and are often delinquent, the social 
toll of syphilis in children is increased. Bazeley and Ander- 
son, 1 in the study noted above, showed that among the 60 
syphilitic and 60 non-syphilitic children considered both from 
the mental and social point of view, there were 20 instances 
of inferiority, 6 of equality and 6 where the syphilitics were 
more favored. The authors concluded: 

i Bazeley and Anderson, loc. eit. 



THE CHILD 95 

. . . of children under 15 years constituting social problems, 
the congenital syphilitics constitute the more serious problems. 
Among them there are more cases of backwardness in school, there are 
more feeble-mindedness and retardation, there are more defects in 
the mental processes (with the one exception of affectivity), there are 
more delinquencies, there are more defects in vision, hearing, and 
speech. And if we consider the single individuals with one or more 
defects, then in the syphilitics there are more individuals with plural 
defects in the mental processes, there are more individuals with plural 
delinquencies, and there are more individuals with plural defects in 
the two main sense organs and in speech. 

Nervous System Diseases as Social Handicap. — The more 
severe forms of congenital syphilis, paresis, cerebrospinal 
syphilis, and tabes incapacitate the child as they do the adult. 
The former cases are, of course, more appealing, as they occur 
in the innocent before they have a real start in life. 

Importance of Early Treatment. — One of the saddest points 
about congenital syphilis is that it is so often unrecognized 
through the carelessness, indifference, or ignorance of parents, 
doctors, social workers, or institutions, and thus the beneficent 
results to be obtained by treatment are lost or delayed to the 
patient. The earlier the treatment is instituted, the better 
the chance of preventing disabling symptoms. We have 
already presented figures 1 showing that in our cases the 
median age for the discovery of congenital syphilis is 9 years. 
This indicates that congenital syphilis exists undiagnosed too 
long. 

Treatment of Syphilitic Parents. — The more hopeful aspect 
of congenital syphilis is treatment. If one may be allowed a 
paradox, the most important factor concerning congenital 
syphilis is its prevention. Congenital syphilitics are the off- 
spring of syphilitic parents. It is possible by adequate and 
well-timed treatment to do much to prevent syphilitic parents 
from giving birth to syphilitic children. Neglected or imper- 
fectly treated syphilis in the husband or prospective father is 
dangerous to the wife and child, especially in the first few 

i See page 91. 



96 SYPHILIS OF THE INNOCENT 

years of the disease. Good treatment of syphilis in the orig- 
inal patient may forestall difficulties. As we have already 
seen, congenital syphilis usually means that the mother has 
had syphilis. Therefore it is more important that the father 
should not infect his wife. If a woman has not had syphilis 
we may assume that she will not give birth to syphilitic chil- 
dren. If, on the other hand, the mother has syphilis, it is 
quite probable that her children will have congenital syphilis. 
While it is true that some syphilitic women give birth to non- 
syphilitic children, for practical purposes we must assume 
that the children will be syphilitic. Adequate antisyphilitic 
treatment of a syphilitic couple will do much to reduce the 
chances of accidents to pregnancies or of the production of 
syphilitic children. Treatment before pregnancy is the best 
insurance for non-syphilitic children. In some instances 
treatment will overcome a potential sterility, and the woman 
who has not had children for many years may, after treat- 
ment, become pregnant and give birth to a healthy child. In 
a similar fashion, treatment may put an end to a series of 
accidents to pregnancies, stillbirths, or early deaths and allow 
the production of a living child. 

Case 71. 1 Mrs. Dempsey was married at the age of 21. When seen 
at 25, she was found to have syphilis, as was her husband. The dura- 
tion of the infection was unknown. During her married life she had 
been pregnant three times, the first two pregnancies resulting in still- 
births, and the third in a living child which lived only three months. 
Antis3 r philitic treatment was administered. Soon after obtaining a 
negative Wassermann reaction the wife was again pregnant, and gave 
birth to a healthy normal child. The Wassermann reaction of the 
mother of the child at the time of the latter 's birth was negative. 
When re-examined again at the age of eight months the child was 
normal. Apparently the result of treatment was the birth of the non- 
syphilitic child. 

When a syphilitic woman is pregnant, treatment is abso- 
lutely demanded in order that the fetus may have a chance 
to develop properly and be born free of syphilis. It is there- 
fore of the utmost importance to be sure that a pregnant 
woman is not syphilitic, and if she is, to place her under treat- 

l Private Case of Dr. Klauder. 



THE CHILD 



97 



ment. Kolrner, 1 in making a plea for the study and preven- 
tion of prenatal syphilis, says that an effort should be made 
to examine the blood of the prospective fathers as well as of 
any pregnant women. He believes that one should regard all 
children as probably syphilitic when one or both of the parents 
have positive Wassermann reactions. 

J. W. Williams 2 found 302 fetal deaths occurring in 4000 
deliveries at the Johns Hopkins Hospital. Syphilis was the 
cause of death in 12.12 per cent among the whites and 45.23 
per cent among the Negroes. Among the 4000 women, a posi- 
tive Wassermann reaction was present in 2.48 per cent of the 
white women and 16.29 per cent of the Negro women. Wil- 
liams divided these cases of syphilis in the women into three 
groups according to the amount of treatment received before 
delivery. In the first group were those who had had no treat- 
ment. Fifty- two per cent of the children born to these 
women were born dead or presented some evidence of syphilis. 
The second group included those who had had insufficient 
treatment, and in this group 37 per cent of the children were 
born dead or were congenital syphilitics. The third group 
was comprised of the women who had what is ordinarily con- 
sidered as adequate treatment and of this group only 7.4 per 
cent of the children showed syphilitic difficulties. These 
figures speak eloquently of the value of treatment. New- 
comer 3 in a smaller series of cases presents concretely the value 
of treatment to the syphilitic pregnant woman. In a series 
of 12 women who were pregnant at the time of observation 
or became pregnant later, nine had had miscarriages. The 
evidence of syphilis was clear in all 12 cases. Six of these 
women were treated during pregnancy and six before they be- 
came pregnant. All 12 gave birth to full-term children who, 
when observed after birth, showed no signs of syphilis and 
had negative Wassermann reactions. 

1 Kolmer, Prenatal Syphilis with a Plea for its Study and Prevention. Ameri- 
can Journal of Diseases of Children, vol. 19, no. 5, May, 1920, pp. 344-348. 

2 Williams, J. W., Significance of Syphilis in Prenatal Care and in the Causa- 
tion of Fetal Death, Bulletin, Johns Hopkins Hospital, vol. 31, May, 1920, 
p. 144. 

3 Newcomer, H. S. et al., One Aspect of Syphilis as a Community Problem, 
American Journal of Medical Sciences, vol. 158, Aug., 1919, p. 141. 



98 



SYPHILIS OF THE INNOCENT 



John Adams 1 of England gives interesting results of treat- 
ment of syphilitic mothers, the majority of whom appeared 
at the clinic when six months pregnant and almost all in the 
secondary stage of the disease. Some had been treated with 
mercury and arsenic and hence showed no obvious lesions. 
Others had had no treatment. Dr. Adams believes that if 
the mother's Wassermann test can be made negative or doubt- 
ful at confinement, the baby will be negative and without signs 
of syphilis. If the mother still has a positive reaction, the 
baby will probably be syphilitic. None of the negative babies 
born of the women treated have become positive since birth 
nor developed signs of syphilis although many had no treat- 
ment except through the mother's milk. The following table 
shows the results of treatment over a three-year period and 
apparently justifies the conclusion that "a pregnant woman 
with syphilis, whether active or latent, if treated for three or 
four months before her confinement will probably be delivered 
of a healthy child at full term. ' ' 



Besults of Treatment of Women During Pregnancy and of the 
Newly Born Children at Thavies Inn Venereal Center (Preg- 
nant Women) 



Years 
Sept. 1 
Aug.. 1 


Mother 
Admitted 

with 
Syphilis 


Babies Born Alive 
Wassermann Reaction 


Babies 
Dying 

OF 

Syphilis 


Fetus 
Stillborn 


Positive 


Negative 


Syphilid 


1917-18 


28 


17 


6 


3 1 


5 


1918-19 


30 


8 


21 


1 (2 mos.) 


1 


1919-20 


37 


1 


36 


None 


None 



l Ages 3, 14, and 36 days, respectively. 

An indication of the incidence of syphilis in pregnant 
women of a clinic group is given in Table 16. The incidence 
as shown by the positive Wassermann reaction in the total 
gronp of 13,331 pregnant women is 6.82 per cent which agrees 
rather closely with the incidence found in 4935 women in Bos- 
ton, among whom 5.87 per cent showed positive Wassermann 
reactions. 

i Adams, John, Pregnancy and Latent Syphilis Results of Three Years ' 
Treatment of Syphilitic Mothers and Babies, The Lancet, vol. 2. Nov. 13, 1920. 
p. 990. 






THE CHILD 



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THE CHILD 101 

It is seen that a syphilitic woman is a menace to her child 
and that treatment is of the utmost importance. If a woman 
is in an actively contagions stage of syphilis and is a menace 
to others besides her child, she can, in states which have com- 
pulsory treatment laws for contagious persons, be forced to 
take treatment. Unfortunately, there are no laws to compel 
a noncontagious syphilitic pregnant woman to take treatment 
although she is infective to the fetus, and although the child, 
if born syphilitic, will be contagious for a time to any who 
come in close association with it. At the present time moral 
suasion seems to be the only and often ineffectual means of 
meeting the situation. 

Case 72. Patrick O'Brien's family (see Case 28) illustrates what 
may happen in syphilitic families when treatment is not given. In 
this typical syphilitic family only one member out of six escaped the 
infection. Syphilis was discovered in this family when the first child 
was born. The mother was not put under treatment. Had this been 
done the history of the family might have been entirely different. In 
such a family one has to consider not only the actual effect of syphilis 
as a disease but its social discomforts. The mother has had to take 
the syphilitic boy to hospitals for treatment over a period of sixteen 
years. This has been a difficult and costly precedure on her part as 
she has had to bear a large share of the burden of the family 's support. 

Case 73. 1 The history of the Charles family is very instructive. 
The father and mother both had ' ' sores, ' ' probably chancres, which re- 
ceived local treatment only. Their first child was stillborn and the 
second child died of hemorrhage of the cord. Before the death of the 
second child, the parents reported to the hospital for treatment but 
refused to continue despite all the efforts made by the social worker. 
Two years later their fourth child was brought to the hospital and 
found to be syphilitic. The third child had died at the age of three 
weeks. When the diagnosis was made on the fourth child and treat- 
ment instituted, the parents agreed to undergo systemic treatment 
themselves. How much better if they had followed advice and had 
done this earlier. One always has to reckon with the individual 
equation of the parents. Education and a thoroughly good system of 
follow-up are necessary in these cases. 

Case 74. Inadequate treatment of the mother may be of very little 
value as is shown by the history of the O'Rourke family. The hus- 

l Children's Hospital, Boston. 



102 SYPHILIS OF THE INNOCENT 

band acquired syphilis before marriage. Soon after marriage the 
mother became pregnant and during this pregnancy she showed 
signs of the secondary stage of syphilis but received no treatment. 
The child was born dead. For six months she took some treatment 
which consisted chiefly of mercury by mouth. She soon became preg- 
nant again and discontinued her treatment. The child was born alive 
but lived only seven days. She again became pregnant and this time 
took treatment during the entire pregnancy. The child was born at 
full term and lived, although it had a positive Wassermann reaction. 
During the next pregnancy she again took some treatment and the 
child again was born at term but was actively syphilitic and developed 
nervous system involvement. 

Case 75. Rose DeMarino was a young woman of 27 years of age 
when she came under observation. The husband acknowledged hav- 
ing had syphilis twelve years ago and two years prior to his marriage. 
Mrs. DeMarino had a positive Wassermann reaction. After four 
miscarriages she was treated by mercurial inunctions. She then gave 
birth to four living children, the oldest of whom, however, was a con- 
genital syphilitic. The result of the untreated syphilis in the mother 
was four miscarriages. After treatment she gave birth to four living 
children and it is to be presumed that because of the inadequacy of 
the treatment the first child had congenital syphilis. Probably had 
treatment been more active this child would also have been free of 
signs of syphilis as were the three children born later. 

Case 76. When Mrs. Smith was five months pregnant it was found 
that she had syphilis. Discovery was made through examining the 
families of syphilitic patients at the hospital, her husband being a 
patient with general paresis. She was immediately put under anti- 
syphilitic treatment and the child when born was found to be quite 
healthy and showed no signs or symptoms of congenital syphilis. A 
second child born later was also free from evidence of syphilis. 

Question of Treatment of Apparently Well Children of 
Syphilitic Parents. — We may now turn to the question of the 
treatment of a congenital syphilitic after birth. Should one 
consider the offspring of all syphilitic parents as syphilitic 
and treat them on this basis? Certainly one should suspect 
children of syphilitics of having syphilis and examine them 
with the utmost care. Attention has already been called to 
the paint of view of some syphilologists who believe that the 



THE CHILD 103 

children of syphilitic parents should be treated irrespective 
of whether they show definite signs or symptoms. Thus, 
Browning and McKenzie 1 say that "a positive Wassermann 
reaction in either parent of a seemingly healthy infant is an 
indication for the treatment of the child also, and this is espe- 
cially the case if the mother reacts positively. ' ' This is an 
extreme point of view and is hardly in keeping with the advice 
of some of the older syphilologists, as Jonathan Hutchinson 
and Fournier, who, as a result of many years of experience, 
felt that many syphilitics give birth to perfectly normal 
healthy children. Observation over a period of years has 
shown that many offspring of syphilitic parents never develop 
any debilitating condition which may be related to an active 
spirochetosis. Thus we feel that treatment is not indicated 
for those offspring who show neither stigmata nor symptoms, 
but rather that they should be kept under close observation. 
It is, of course, possible, if one does not treat all the offspring 
of syphilitic parents, that a certain number of children who 
have apparently been free from the disease will develop late 
symptoms. That is, children who have shown no signs or 
symptoms during a period of years may later develop some 
syphilitic disorder. It is not probable, however, that this 
will occur with any great frequency, and for practical pur- 
poses it would seem safer not to treat children who show 
nothing either in the way of stigmata, symptoms, or laboratory 
findings suggestive of the disease. 

Treatment in Infancy and Early Childhood; Prognosis. — 

If one does not hold to the view that all offspring of syphilitic 
parents, or particularly of syphilitic mothers, should be 
treated, then the basis for treatment must be stigmata or 
symptoms of the disease. It is obvious that a syphilitic infant 
should receive treatment from the earliest possible moment. 
The attempt should always be made to treat a syphilitic child 
before the appearance of symptoms such as interstitial kera- 
titis, deafness, or other manifestations. This is quite possible 
in those cases in which symptoms appear late. When, how- 

i Browning, C. H. and McKenzie, Recent Methods in the Diagnosis and Treat- 
ment of Syphilis, Philadelphia, Lea and Febiger, 1912, p. 111. 



104 SYPHILIS OF THE INNOCENT 

ever, the symptoms appear in the first weeks of life, all atten- 
tion must be directed toward treating the symptoms. Where 
treatment is instituted early some very successful results may 
be obtained. The children who have severe early symptoms 
such as pemphigus and marasmus often improve very rapidly 
under antisyphilitic treatment. 

Case 77. Helen Morrison was five weeks old when she was first seen. 
She was covered with a rash which made the diagnosis of congenital 
syphilis possible at first sight. She was a poor little undernourished 
baby. She was taken into the hospital and with good care and anti- 
syphilitic treatment made marked improvement. After the open 
lesions were healed and the child no longer was considered contagious 
she was placed by a child-placing agency in a foster home, the foster 
parents understanding the conditions of the case. At the age of 
thirteen months this little lady was very precocious. She had a 
vocabulary of a number of words and was walking. She was a pretty 
little child, showing no stigmata. She was still small, weighing only 
fourteen pounds, but had gained considerably in the previous few 
months, and by the aid of proper hospital and medical treatment com- 
bined with good social service care she was showing every indication 
of good health and good mental development. 

An early diagnosis of syphilis in children is, therefore, of 
very great importance. As has been seen, the diagnosis of 
congenital syphilis is based chiefly upon stigmata, symptoms, 
and history of the child, supplemented by family history and 
examination. It would seem fair to state that every child 
who shows either definite stigmata of congenital syphilis or 
symptoms of the disease or a combination of both, should 
have treatment. We would hold that every child with defi- 
nite stigmata which make a diagnosis of congenital syphilis 
certain should have treatment whether or not symptoms are 
present. Thus, Hutchinsonian teeth in a child of syphilitic 
parentage is rather definite evidence that syphilis has caused 
some change in the organism and that the child should receive 
treatment, though he has shown no other signs of the activity 
of the disease. The Wassermann reaction is one of the most 
important symptoms of congenital syphilis, yet a negative 
Wassermann reaction is of no more significance than the 
absence of other signs or symptoms of syphilis. Where there 



THE CHILD 105 

is evidence that congenital syphilis is present, a negative 
Wassermann reaction has no real bearing on the question of 
treatment. It must be thoroughly recognized that in con- 
genital syphilis, as in the acquired form, there may be long 
periods of apparent latency in which no symptoms, with the 
possible exception of the Wassermann reaction, appear. When 
the Wassermann reaction is consistently positive, the evidence 
that syphilis is present in an active form is weighty enough to 
demand radical treatment. Both logic and experience seem 
to show that later manifestations may be prevented by the 
treatment of children who have a positive Wassermann reac- 
tion but no other symptoms of the disease. It is, of course, 
difficult to say this with great definiteness, as one is here deal- 
ing with the subject of preventive medicine. If no symptoms 
develop one is never able to say that they would have devel- 
oped if treatment had not been given. Preventive therapy is 
never startling, as it offers no brilliant pictures. A vast 
amount of experience will be necessary to show just how much 
can be accomplished by the treatment of congenital syphilitics 
who are free from symptoms. The experience at hand, 
however, seems to justify the value of thorough treatment. 

Often when congenital syphilitics are treated and relieved 
of present symptoms one cannot give an entirely good prog- 
nosis or the assurance that no later symptoms will develop. 
Cases of interstitial keratitis or other late manifestations may 
appear in children who have been well treated. In other 
words, we have no definite cure for all cases of congenital 
syphilis. Without much question, the number of symptoms 
may be very markedly decreased by treatment. The great 
difficulty in the amassing of facts concerning the value of 
treatment in congenital syphilis is due to the difficulty in 
following cases over a long period of years. The value of a 
well-run follow-up service is nowhere greater than in this field. 
All the evidence we have at the present time goes to show the 
great good that can be accomplished by the treatment of con- 
genital syphilis. This is certainly obvious in the results that 
are obtained in the treatment of the earlier manifestations, 
and as one can remove symptoms it is most probable that one 
can be successful in preventing them. The most satisfactory 



106 SYPHILIS OF THE INNOCENT 

effect of treatment of a congenital syphilitic is seen in the 
general constitutional improvement. Children who are feeble, 
weak, and poorly developed, will often begin to show immedi- 
ate improvement upon the administration of adequate early 
treatment. After many years have elapsed and the organism 
has secured a definite footing in the deeper structures of the 
body and has succeeded in thriving despite the resistance of 
the patient, results are often much more difficult to obtain. 
Thus, in interstitial keratitis, a condition in which relatively 
non-vascular regions of the eye are involved, the effects of 
treatment are not nearly so brilliant. Certainly one does not 
obtain the magical results that are shown in the treatment of 
many other types of lesion. There are some oculists who are 
not very enthusiastic about the systemic treatment and its 
results on the eye condition. Such treatment even in inter- 
stitial keratitis seems gradually to be winning more esteem. 
Thus Posey 1 says that the outcome of a case of interstitial kera- 
titis in which the individual is given thorough antisyphilitic 
treatment should be better than in those which are not thus 
treated. Scarring, which interferes with vision, is apparently 
considerably reduced when treatment is thorough and ade- 
quate, and the tendency to recurrence of the difficulty is greatly 
reduced. In certain of the severe late nervous system mani- 
festations, such as juvenile paresis and nerve deafness, the 
results are not good. In these conditions, however, we are 
dealing with a situation which is entirely identical with that 
found in acquired syphilis, and the treatment should not be 
considered any more discouraging than that of cases of 
acquired syphilis in adult life where treatment has been too 
long delayed. 

Type of Treatment. — The type of treatment that a congen- 
ital syphilitic should receive is something that cannot be laid 
down in dogmatic fashion. This is also true in regard to 
treatment of syphilis in general. Individual conditions make 
different methods of treatment advisable, and the ideas of 
different syphilologists demand variations in the regimen of 
treatment. In the days before the introduction of arsphen- 

i Posey, Hygiene of the Eye, Philadelphia, Lippincott, 1918. pp. 164-168. 



THE CHILD 107 

ainin, fairly good results were obtained by the use of mercury 
over a period of a great many years. Mercury by mouth has 
its chief value in cases of congenital syphilis, and many excel- 
lent results have been obtained by the feeding of mercury and 
chalk to syphilitic infants. Hochsinger 1 gives some interest- 
ing figures on the chances of ultimate recovery in a series of 
cases of congenital syphilis treated before the days of 
arsphenamin. Of 263 cases under observation from four to 
twelve years, 79 died. One hundred and twelve had symptoms 
(not always syphilitic) and 72 were free from symptoms of 
any kind. Because of the good results that may be obtained by 
the use of mercury in the treatment of congenital syphilis it 
becomes obvious that one must use this drug in practically 
every case, although other forms of medication may be added. 
Arsphenamin produces some excellent results and may be 
used from the very early days of life. Clinical experience 
seems to show that lives of seriously ill syphilitic infants may 
be saved by the early administration of arsphenamin. The 
treatment of the nursing mother may also have some valuable 
therapeutic effects upon the child. This, however, does not 
seem to be nearly as effective as the introduction of the drugs 
directly into the system of the child. A combination of mer- 
cury and arsphenamin is probably the best method. Potas- 
sium iodide has its place in the treatment of congenital 
syphilis as well as in acquired syphilis. The treatment of 
congenital syphilis must be continued over a period of many 
years. It is doubtful if there is any exception to this state- 
ment. Certainly conservative judgment indicates that one 
must continue treatment for a long period if one wishes to be 
sure of results. 

What has been said about the type of treatment of the 
infant holds equally for congenital syphilitics whose treatment 
begins later in life. The combination of arsphenamin and 
mercury is also indicated over a period of years. It should 
be emphasized that a negative Wassermann reaction obtained 
during treatment is not an indication that the child is cured 
of syphilis. Treatment should be persistent despite nega- 

i Griffith, op. cit., p. 578. quotes Hochsinger, Ergebn. d. inn. Med. u. Kinderh.. 
vol. 6, 1910, p. 125. 



108 SYPHILIS OF THE INNOCENT 

tive Wassermann reactions. It goes without saying that a 
positive Wassermann reaction is evidence that cure has not 
been effected. By a continuation of treatment over a period 
of years it is often possible to obtain a condition in which no 
symptoms of syphilis appear and in which the Wassermann 
reaction becomes and remains negative. 

Advantages of Hospital Schools. — The necessary care and 
hygiene of syphilitic children, which is equal in importance 
to the administration of antisyphilitic remedies, often cannot 
be properly given if the child remains at home. It is also 
difficult to secure the parents' cooperation for a long con- 
tinued period of out-patient treatment. When a child has 
active symptoms it is, at times, possible to obtain a place for 
him in the hospital where treatment can be carried out to 
better advantage ; but when the active symptoms have disap- 
peared this is no longer practical. Frequently the child is in 
such a condition that it is impossible for him to attend the 
ordinary schools. This is true of many children with inter- 
stitial keratitis and other eye conditions, deafness, difficulty 
with locomotion, and the like. Stokes 1 suggests that these 
difficulties could be remedied if the plan of Welander, the 
Scandinavian, were copied in America. Welander established 
hospital schools where children could secure antisyphilitic 
treatment, excellent care, and education, simultaneously. 
Baize 2 says that the child enters the hospital school early and 
receives regular treatment for at least three years. Under 
these conditions the child receives steady prolonged treatment 
as well as education, which is impossible in out-patient clinics 
or hospital wards. The hospital schools have a special medi- 
cal personnel, with special methods of treatment adapted to 
children of different ages, proper hygiene, and educational 
courses for the children of school age. The Journal of the 
American Medical Association reviews Mtiller's and Singer's 3 

i Stokes, J. H., The Third Great Plague, Philadelphia and London, W. B. 
Saunders, 1917, p. 108. 

2 Baize, F., Asylums for Children with Inherited Syphilis, Bulletin de 
I'Academie de Medecine, Paris, vol. 81, June 17, 1919, p. 811. 

3 Miiller and Singer, Fate of Syphilitic Children, Archiv fur Kinderheillcunde, 
Stuttgart, May 17, 1919, vol. 67, nos. 3 and 4 (reviewed in the American Medical 
Association Journal). 



THE CHILD 109 

results from such hospital schools in Germany, where they 
were started in 1909. Eighty-four of the children had been 
in the schools from two to ten years. Better results appar- 
ently were obtained by their prolonged treatment under the 
hospital conditions than by any other means. 

It must be remembered that the aim of treatment of early 
and late congenital syphilitics, those with little damage done 
and those in a serious condition, is to minimize the social 
handicap of the congenital syphilitic and to allow him to take 
his place in the everyday world. Time, only, can tell how far 
we have progressed towards accomplishing this end, but that 
we have gone a considerable distance in this direction is 
certain, and that we can go much further is probable. 

REFERENCES 

Adams, J., Pregnancy and Latent Syphilis. Result of Three Years' Treatment 
of Syphilitic Mothers and Babies, The Lancet, vol. ii, Nov. 13, 1920. 

Atwood, C. E., Idiocy and Hereditary Syphilis, Journal of the American Medical 
Association, vol. 55, Aug. 6, 1910. 

Balze, F., Asylums for Children with Inherited Syphilis, Bull, de VAcad. de 
med., Paris, vol. 81, June 17, 1919. 

Bazeley and Anderson, Mental Features of Congenital Syphilitics, Boston 
Medical and Surgical Journal, vol. 173, no. 26, Dec. 23, 1915. 

Blaisdell, J. H., The Menace of Syphilis of To-day to the Family of To- 
morrow, Boston Medical and Surgical Journal, vol. clxxv, no. 1, July 6, 
1916. 

Browning, C. H. and McKenzie, Becent Methods in the Diagnosis and Treat- 
ment of Syphilis, Philadelphia, Lea and Febiger, 1912. 

Bulkley, L. D., Syphilis in the Innocent, New York, Bailey and Fairchild, 
1898. 

Bureau of the Census, Department of Commerce, Washington, Government 
Printing Office, 1916. 

Charcot, M., Clinique des Maladies du Systeme Nerveux, Paris, Veuve Babe 
et Cie, 1892. 

DeBuys, L. R. and Maude Loeber, Study in a Foundling Institution to De- 
termine the Incidence of Congenital Syphilis, Journal of the American 
Medical Association, Oct. 4, 1919. 

Derby G. and C. B. Walker, Interstitial Keratitis of Luetic Origin, Transac- 
tions of the American Ophthalmological Society, 1913. 

Diday, P., A Treatise on Syphilis in New-lorn Children and Infants at the 
Breast, translated by'G. Whitley, London, the New Sydenham Society, 1859. 

Fournier, A., La Syphilis Hereditaire Tardive, Paris-, G. Masson, 1896. 

, Treatment and Prophylaxis of Syphilis, English translation of the second 

edition, revised and enlarged by C. F. Marshall, American edition revised 
and corrected with an appendix by George M. Mackee, New York, Rebman. 

Freud, S., Three Contributions to the Sexual Theory (Brill's translation), Nervous 
and Mental Disease Publishing Co., 1910. 



110 SYPHILIS OF THE INNOCENT 

Griffith, J. P. C, The Diseases of Infants and Children. Philadelphia. Saunders, 
1919. 

Habermann, Hereditary Syphilis, Journal of the American Medical Association, 
vol. 64, no. 14, April 3, 1915. 

Haines, T. H., Incidence of Syphilis Among Juvenile Delinquents, Journal of 
the American Medical Association, vol. 66, no. 2, 1916. 

Hochsinger, Die gesundheitlichen Lebenschicksale, Wiener Iclmische Wochen- 
schrift, vol. 24, June 16, 1910. 

Infant Mortality Series, no. 3, Children's Bureau Publication, no. 9, Washing- 
ton, D. C, 1915. 

Jeans, P. C, A Review of the Literature of Syphilis in Infancy and Childhood, 
American Jmirnal of Diseases of Children, vol. 20, no. 1, July, 1920. 

, Cerebrospinal Involvement in Hereditary Syphilis, American Journal of 

Diseases of Children, vol. 18, no. 3, Sept., 1919. 

, Familial Syphilis. American Journal of Diseases of Children, vol. xi, 

no. 1, Jan., 1916. 

, Syphilis and Its Relation to Infant Mortality, American Jmirnal of 

Syphilis, vol. 3, no. 1, Jan., 1919. 

and E. Butler, Hereditary Syphilis as a Social Problem, American 

Journal of Diseases of Children, vol. 9, no. 5, Nov., 1914. 

Kingery, L. B., A Study of the Spinal Fluid in Fifty-two cases of Congenital 
Syphilis, Journal of the American Medical Association, vol. 76, no. 1, Jan. 1, 
1921. 

Kolmer, Prenatal Syphilis, with a Plea for its Study and Prevention, Ameri- 
can Journal of Diseases of Children, vol. 19, no. 5, May, 1920. 

Kraepelin, E., Psychiatrie, eighth edition, Leipzig, vol. iii, 1913. 

Lucas, W. P., Contributions to the Neurology of the Child. II. Note on the 
Mortality and the Proportion of Backward Children in Cases of Congenital 
Syphilis Followed Subsequent to Hospital Treatment, Boston Medical and 
Surgical Journal, Feb. 29, 1912, Aug. 29, 1912, Sept. 4, 1913. 

, Study for Massachusetts Society for Sex Education. Unpublished. 

MtiLLER and Singer, Fate of Syphilitic Children, Archiv fur Kinderheilkunde, 
Stuttgart, May 17, 1919, vol. 67, nos. 3 and 4 (reviewed in the Journal of 
the American Medical Association). 

Newcomer, H. S., et al., One Aspect of Syphilis as a Community Problem, 
American Journal of Medical Sciences, vol. 158, Aug., 1919. 

Nonne, M., Syphilis and Nervensystem, Dritte neubearbeitete Auflage, Berlin, 
Verlag von S. Karger, 1915. 

Plaut and Goring, L T ntersuchungen an Kindern und Ehegatten von Paralytiken, 
Miinchener medisinische Wochenschrift, vol. 58, no. 37, Sept. 12, 1920. 

Posey, Hygiene of the Eye, Philadelphia, Lippincott, 1918. 

Pusey, W. A., Syphilids as a Modern Proolem, Chicago, American Medical As- 
sociation, 1915. 

Ricord, Lectures on Venereal and other Diseases, translated by V. de Merie, 
Philadelphia, 1849. 

Report of the Commission on Venereal Diseases, Final Report of the Com- 
missioners, London, 1916. 

Solomon, H. C. and M. H., The Effects of Syphilis on the Family of Syphilitic* 
Seen in the Late Stages, Social Hygiene, vol. vi, no. 4, Oct., 1920. 

Still, G. P., Congenital Syphilis, System of Syphilis, second edition, London, 
vol. 1, no. 1, 1914. 



THE CHILD 111 

Stokes, J. H., The Third Great Plague, Philadelphia and London, W. B. 

Saunders, 1917. 
, To-day's World Problem in Disease Prevention, Issued by the U. S. 

Public Health Service, Treasury Department, Washington, D. C. 
Vedder, E. B., Syphilis and Public Health, Philadelphia and New York, Lea 

and Febiger, 1918. 
Veeder, B. S. 3 Hereditary Syphilis in the Light of Recent Clinical Studies, 

American Journal of the Medical Sciences, vol. clii, 1916. 
Williams, J. W., Significance of Syphilis in Prenatal Care and in the Causation 

of Fetal Death, Bulletin of the Johns Hopkins Hospital, vol. 31, May, 1920. 



■d a 



CHAPTER IV 

THE FAMILY 

Syphilis as a Family Disease. — It is important to remember 
that syphilis not only affects the mate and offspring as indi- 
viduals but also as members of a family group. Syphilis 
threatens the stability of family life, whether it enters early 
or late, whether it strikes one member or all members. It is a 
disease which once having attacked a family affects its social 
and economic life as well as the health of the individual mem- 
bers. The entire family morale may be weakened by over- 
fear of infection or callousness; by attaching too much or 
too little importance to future difficulties; by exaggerating or 
minimizing any changes in the home situation. The economic 
status of the family, its industrial level, and standard of living 
are often affected. The community, a network of families, 
then bears part of the economic burden. 

Statistics on Incidence in Families. — In our study of 555 
families of syphilitics 1 given in the preceding chapters, we 
have shown statistically the specific results on the mate and 
child. Further figures from the study give the effects of 
syphilis with the family rather than the individual as a unit. 
For purposes of comparison with our tables we have inserted 
wherever possible similar figures from other authors. 

Families in Which Positive Wassermann Reaction Ap- 
peared. — The tables on familial syphilitic involvement include 
five tables from our study and two tables compiled from 
studies by other authors. Table 17 shows the number of fami- 
lies in which some member aside from the original patient had 
a positive Wassermann reaction. Of the 191 families in which 
all members were examined, a positive Wassermann reaction 

l Solomon, H. C. and M. H., The Effects of Syphilis on the Families of 
Syphilitics Seen in the Late Stages, Social Hygiene, vol. vi, no. 4, Oct., 1920. 

112 



THE FAMILY 113 

occurred in 30 per cent, whereas, in the 364 families in which 
every member was not examined, it occurred in but about 19 
per cent. The difference in percentage may be accounted for 
by the fact that in the group in which not all members were 
examined (364) a larger or smaller number of the unexamined 
might have shown a positive Wassermann reaction, while the 
all-examined group (191) was, of course, unconsciously selected 
according to the ease with which members could come in, size 
of families, etc. It follows however, that somewhere between 
19 per cent and 30 per cent would be the correct figure if 
every member of the original group of 555 families had been 
examined; that is, it would undoubtedly be higher than 19 
per cent and less than 30 per cent. In the larger group (555), 
a positive Wassermann reaction occurred in 22.8 per cent of 
the families. This figure of 22.8 per cent which would 
probably be close to the correct figure had all members been 
examined, is typical of what may be expected in any clinic 
dealing with late syphilitics when an effort is made to bring 
the spouse and children of syphilitic patients to the clinic for 
examination. 

Families with no Children. — Table 18 is concerned with 
the percentage of families in which no living children were 
born. The families in which no successful pregnancies oc- 
curred may be divided into families which were entirely 
sterile, and those in which pregnancies occurred which never 
came to successful fruition. The tables dealing with the total 
555 families may be considered as giving the correct per- 
centage for this study, which is based upon history. It was 
found that 29.7 per cent of the families did not give birth to 
living children, 23 per cent being entirely sterile, and 6.7 per 
cent having unsuccessful pregnancies. It must be borne in 
mind that we are not here dealing with the question of acci- 
dents to pregnancies as such, but merely with the number of 
childless families. Not all of the sterile or childless mar- 
riages can be definitely traced to syphilis. Gonorrhea, pelvic 
deformities, mismating, and the like, may account for much 
of it. However, if we compare this figure of 29.7 per cent 



114 



SYPHILIS OF THE INNOCENT 

TABLES SHOWING FAMILIAL 



-191 Families in Which Evert Living 
Member Was Examined 



Class 



General 
Paresis 



Cerebro- 
spinal 
Syphilis 



Nervous 

system not 

involved 



Total 



TABLE 17 










FAMILIES IN WHICH 




No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 




150 
37 

2 


100.0 
25.1 

1.4 


9 
4 




100.0 
50.0 


32 

8 

4 


100.0 

28.5 

14.3 


191 
49 

6 


100.0 


Families with positive Wassermann in one member 
Families with positive Wassermann in more than 


26.7 
3.3 






Total families with positive Wassermann in one 
or more members 


39 


26.5 


4 


50.0 


12 


42.8 


55 


30.0 



TABLE 18 










FAMILIES WITH 




No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 




150 
53 

9 


100.0 
35.3 

6.0 


9 

1 

1 


100.0 
11.1 

11.1 


32 
11 

6 


100.0 
34.4 

18.7 


191 
85 

16 


100.0 


Families with no pregnancies 


34.0 


Families with no children, but with abortions, mis- 


8.4 








62 


41.3 


2 


22.2 


17 


53.1 


81 


42.4 







TABLE 19 












BIRTH-RATE 


AND 






No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 




150 
75 
1.33 
1.06 


100.0 
50.0 


9 

6 

1.89 

1.44 


100.0 

66.7 


32 
13 
1.29 
.94 


100.0 
40.6 


191 
94 
1.35 
1.06 


100.0 
50.0 


Families with living children 




Average number of living children 


per family 





TABLE 20 



FAMILIES WITH DEFECTS 





No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


Total families 


150 
53 

9 

8 
24 


100.0 
35.3 

6.1 

5.3 

16.0 


9 
1 

1 



2 


100.0 
11.1 

11.1 
22.3 


32 

11 

6 
4 
3 


100.0 
34.4 

18.8 

12.5 

9.3 


191 
65 

16 

12 

29 


100.0 


Families with no pregnancies 


34.0 


Families with no children, but with abortions, mis- 
carriages, or stillbirths . 


8.4 


Families with positive Wassermann reaction in 
children 


6.3 


Families with non-syphilitic children, but accidents 
to pregnancies 


152 






Total families with defects as to children 


94 
56 


62.7 
37.3 


4 
5 


44.5 
55.5 


24 

8 


75.0 
25.0 


122 
69 


63-9 


Total families with no defects as to children 


36-1 


Total 


150 
43 


100.0 

28.6 


9 
3 


100.0 
33.3 


32 

8 


100.0 
25.0 


191 
54 


100.0 


Families with no defect as to children or Wasser- 
mann reaction in spousef 


28-2 



TABLE 21 










FAMILIES WITH 




No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 




150 
97 

35 


100.0 
64.7 

36.0 


9 

8 

3 


100.0 
88.9 

37.5 


32 
21 

12 


100.0 
65.6 

57.1 


191 
126 

50 


100 


Families with pregnancies 

Families in which abortions, miscarriages, and still- 
births occurred^ 


66.0 
39.7 



* There are a few families in which there was neither living spouse nor child, 
nancies is discussed (Table 18) but not in the Wassermann reaction percentages 

t These percentages were taken on the total families although there were a few 
there was no living spouse to examine. The assumption was that the spouse was 

t These percentages were taken on families with pregnancies. 



THE FAMILY 



115 



SYPHILITIC INVOLVEMENT 



B — 364 Families in Which One or More 

Members Besides the Patient 

was Examined 


C — 555 Families, Total of A and B 


General 
Paresis 


Cerebro- 
spinal 
Syphilis 


Nervous 

system not 

involved 


Total 


General 
Paresis 


Cerebro- 
spinal 
Syphilis 


Nervous 

system not 

involved 


Total 



POSITIVE WASSERMANN REACTION APPEARED 














No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


192 
36 

8 


100.0 
19.6 

4.3 


48 
2 

3 


100.0 
4.3 

6.4 


124 
12 

6 


100.0 
10.0 

5.0 


364 
50 

17 


100.0 
14.3 

4.8 


342 
73 

10 


100.0 
22.0 

3.0 


57 
6 

3 


100.0 
10.9 

5.5 


156 
20 

10 


100.0 
13.5 

6.8 


555 
99 

23 


100.0 
18.5 

4.3 


44 


23.9 


5 


10.6 


18 


15.0 


67 


19.0 


83 


25.0 


9 


16.4 


30 


20.3 


122 


22.8 



NO CHILDREN 



No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


192 
34 

8 


100.0 
17.7 

4.2 


48 
8 

4 


100.0 
16.7 

8.3 


124 
21 

9 


100.0 
16.9 

7.3 


364 
63 

21 


100.0 
17.3 

5.7 


342 
87 

17 


100.0 
25.4 

5.0 


57 
9 

5 


100.0 
15.8 

8.8 


156 
32 

15 


100.0 
20.5 

9.6 


555 
128 

37 


100.0 
23.0 

6.7 


42 


21.9 


12 


25.0 


30 


24.2 


84 


23.0 


104 


30.4 


14 


24.6 


47 


30.1 


165 


29.7 



AVERAGE NUMBER OF LIVING CHILDREN PER FAMILY 



No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


192 

145 
2.32 
1.90 


100.0 
75.5 


48 

33 
2.96 
2.45 


100.0 
68.6 


124 
80 
2.34 
1.75 


100.0 
64.5 


364 

258 
2.41 
1.92 


100.0 
70.9 


342 

220 
1.89 
1.53 


100.0 
64.3 


57 
39 

2.79 

2.28 


100.0 
68.4 


156 
93 
2.12 
1.58 


100.0 
59.6 


555 

352 
2.05 
1.62 


100.0 
63.4 



AS TO CHILDREN OR WASSERMANN 


REACTION IN SPOUSE 










No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


192 
34 


100.0 
17.7 


48 
8 


100.0 
16.7 


124 
21 


100.0 
16.9 


364 
63 


100.0 
17.3 


342 

87 


100.0 
25.5 


57 
9 


100.0 
15.8 


156 
32 


100.0 
20.5 


555 
128 


100.0 
23.0 


8 


4.2 


4 


8.3 


9 


7.2 


21 


5.8 


17 


5.0 


5 


8.8 


15 


9.7 


37 


6.7 


15 


7.8 


1 


2.1 


8 


6.5 


24 


6.6 


23 


6.7 


1 


1.7 


12 


7.7 


36 


6.5 


38 


19.8 


16 


33.3 


24 


19.4 


78 


21.4 


62 


18.1 


18 


31.6 


27 


17.3 


107 


19.3 


95 
97 


49.5 
50.5 


29 
19 


60.4 
39.6 


62 
62 


50.0 
50.0 


186 
178 


51.1 
48.9 


189 
153 


55.3 
44.7 


33 
24 


57.9 
42.1 


86 
70 


55.2 
44.8 


308 

247 


55.5 
44.5 


192 


100.0 


48 


100.0 


124 


100.0 


364 


100.0 


342 


100.0 


57 


100.0 


156 


100.0 


555 


100.0 


64 


33.3 


17 


35.4 


49 


39.5 


130 


35.7 


106 


31.0 


20 


35.1 


57 


36.5 


183 


30.3 



ACCIDENTS TO PREGNANCIES 






















No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


192 
158 

50 


100.0 
82.3 

31.6 


48 
40 

19 


100.0 
83.3 

47.5 


124 
103 

37 


100.0 
83.1 

35.9 


364 
301 

106 


100.0 
82.7 

35.2 


342 
255 

85 


100.0 
74.6 

33.3 


57 
48 

22 


100.0 
84.2 

46.0 


156 
124 

49 


100.0 
79.5 

39.5 


555 
427 

156 


100.0 
76.9 

36.5 



These are included in the total number of families when the subject of preg- 
nable 17). 

families in which the children were non-syphilitic as far as known but in which 
non-syphilitic. 



116 



SYPHILIS OF THE INNOCENT 



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THE FAMILY 



117 



Table 23. Sterility, Birth-rate, and Average Living Children in 
Non-syphilitic Families 



Sources 


Families 

op 

Harvard 

and 

Yale 

Graduates 

(1850-1890)1 


Census 
Figures 
of R. I. 
Women 
Married 
10-19 
Years, 
Foreign 

and 
Native 
Born2 


Children's i 
Bureau 
Figures 
on 1491 
Married 
Mothers 
of Babies 
Born in 

1911 IN 

Johnstown , 
Pa.s 


Jeans' 
Families 
Showing 

No 
Obvious 
Syphilis 4 


Harmon; 

Poor 
Families, 
Known- 
Cases of 
Syphilis, 
Excluded 5 




No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P. C 


Total families 










1491 


100.0 


200 


100.0 


150 


100.0 


Families with no 
children 




19-23 




11.3 














Birth-rate per family 


2.6 




3.8 




3.59 




3.99 




4.98 




Average number of 
living children per 
family 










3.06 




3.34 




4.36 





1 Solomon, H. C. and M. H., op. cit. p. 479. 

2 Hill, J. A., Comparative Fecundity of Women of Native and American 
Parentage in the United States of America, American Statistical Association, 
Boston, Dec., 1913, p. 583. 

3 Infant Mortality. Series no. 3, Children's Bureau Publication, no. 9, 
Washington, D. C, 1915. 

4 Jeans, P. C. and E. Butler, Hereditary Syphilis as a Social Problem, 
American Journal Diseases of Children, vol. 8, Nov., 1914, p. 333. 

5 Harmon, B., Report of the Commission on Venereal Diseases, Final Report 
of the Commissioners, London, 1916, p. 149. 



representing the number of childless families in our group, 
with that found in a general survey, 1 (Table 23) it is clear 
that the figures obtained from a group of syphilitic fami- 
lies is very much higher. An analysis of native white Rhode 
Island women, 45 years of age, who had been married 
from ten to nineteen years, shows that 17.5 per cent were 
childless. Including the foreign-born women, 11.3 per cent 
were childless. This latter group is comparable to the patients 
at our clinic who represent the same races as the group on 
which the above census report is based. 2 A comparison of 
these figures (29.7 per cent and 11.3 per cent) leaves no doubt 
that syphilis is a very large factor in the production of 
sterility and childlessness. It must be remembered that in 
this discussion we are dealing with the family of the late 

i It must be remembered that all general surveys include a certain percentage 
(approximately 10 per cent) of syphilitic individuals hence the contrast between 
our figures and those of a non-syphilitic group is greater than is apparent. 

2 Hill, loc. cit. 



118 



SYPHILIS OF THE INNOCENT 



TABLES SHOWING ACCI 



Class 



A — 191 Families in which Evert Living 
Member was Examined 



General 
Paresis 



Cerebro- 
spinal 
Syphilis 



Nervous 

system not 

involved 



Total 



TABLE 24 



RELATION OF ABORTIONS, 



No. 



Total pregnancies 

Total abortions 

Total miscarriages 

Total stillbirths 

Average pregnancies per family 

TABLE 25 

Live births 

Stillbirths 

Number of stillbirths per 100 live births 



263 



71 
50 \ 



1.76 



P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


100.0 


23 


100.0 


56 


100.0 


342 


24.0 


!) 


26.0 


■it 


26.8 


8 1 
65 

11 ] 




2.55 




1.75 




1.79 



P.C. 



100.0 
24.5 



PERCENTAGE OF 



No. 



200 
6 
3.00 



P.C. 



100.0 



No. [P.C. 



17 
3 

17.70 



100.0 



No. 



41 
2 
4.90 



P.C. 



100.0 



No. 



258 
11 
4.26 



P.C. 



100.0 



Table 26. Accidents to Pregnancies 



Clinics: 


Holti 


Jeans 2 


Veeder 3 


Haskell 4 


Jamieson 5 


Post's 


Harmon 7 




No. 
193 


P.C. 


No. 


P.C. 


No. | P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


Total families 


100 




100 




86 
167 




74 




30 




150 




Total pregnancies 


427 


100.0 


453 


100.0 


331 


100.0 


100.0 


253 


100.0 


168 


100.0 


1001 


100.0 


Total accidents to 
pregnancies 


123 


28.8 


116 


25.6 


131 


39.6 


42 


25.2 


95 


37.5 


53 


31.6 


172 


17.2 


Average pregnancies per 
family 


2.22 




4.53 




3.31 




1.94 




3.55 




5.6 




6.66 





i Bartlett, F. H., Effect of Venereal Disease on Infant Mortality, American Journal 
of Syphilis, vol. ii, no. 1, Jan., 1918. p. 160.. quotes Holt. 

2 Jeans, op. cit., p. 119. 

3 Veeder. loc. cit. 

4 Haskell, op. cit., p. 891. 

5 Jamieson, op. cit., p. 525. 

6 Post, op. cit., p. 119. 

7 Harmon, B., op. cit., p. 149. 

8 Habermann, J. V., Hereditary Syphilis, Journal of the American Medical As- 
sociation, vol. lxiv, no. 14, 1915, p. 1141, quotes Hochsinger. 



THE FAMILY 



11J> 



DENTS TO PREGNANCIES 



B — 364 Families in Which one or More 
Members Besides the Patient 
Was Examined 



C — 555 Families, Total of A and B 



General 
Paresis 



i Cerebro- 
spinal 
Syphilis 



Nervous 

system not 

involved 



Total 



General 
Paresis 



Cerebro- 
spinal 
Syphilis 



Nervous 

system not 

involved 



Total 



MISCARRIAGES, AND STILLBIRTHS TO PREGNANCIES 



No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C 


536 


100.0 


185 


100.0 


369 


100.0 


1090 


100.0 


799 


100.0 


208 


100.0 


425 


100.0 


1432 


100.0 


7 
69 \ 

15] 


17.0 


°1 
40 

3j 


23.2 


6 H 

11 J 


21.4 


81 

176 } 

29 j 


19.5 


14] 

119 \ 

21 j 


19.2 


1 

11 


23.6 


21 
79 ^ 

13 j 


22.0 


16] 

241 \ 

40 J 


20.7 


2.79 


3.85 




2.98 




2.99 




2.34 




3.65 




2.72 




2.58 





LIVE BIRTHS AND STILLBIRTHS 



No. 


P.C. 


No 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


445 
15 
3.37 


100.0 


142 
3 
2.11 


100.0 


290 
11 
3.79 


100.0 


877 
29 
3.31 


100.0 


645 
21 
3.25 


100.0 


159 
6 
3.80 


100.0 


331 
13 
4.00 


100.0 


1135 
40 
3.52 


100.0 



as Shown by Other Clinics 



Hoch- 

SINGER8 


FOTTRNIER» 


Raven 10 


NONNE 11 


Hoch- 

SINGER 12 


1 
Tarnier 13 


COUTTS" 


PlLETJR 15 


FOURNIER 1 * 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No 


P.C. 


No. 


P.C. 


134 




100 




90 




82 




67 




42 
















569 


100.0 


200 


100.0 


350 


100.0 


319 


100.0 


266 


100.0 


90 


100.0 


1102 


100.0 


414 


100.0 


167 


100.0 


253 


44.4 


140 


70.0 


101 


28.9 


85 


26.6 


124 


46.6 


56 


62.0 


376 


34.1 


154 


37.2 


145 


86.8 


4.25 




2.0 




4.26 




3.89 




3.98 




2.14 

















9 Gow, W. J., Syphilis in Obstetrics, System of Syphilis, second edition.. London, 
Frowde, Hodder and Stoughton, vol. 2, 1914. pp. 354-5, quotes Fournier. 
io Habermann, op. cit., quotes study of Nonne material by Raven. 

11 Nonne, op. cit., p. 403. 

12 Hochsinger, K., Die gesundheitlichen Lebensschicksale erbsyphilitischer Kinder, 
Wiener Tdinisclie Wochensohrift, no. 24, June 16, 1910, p. 882. 

13 Bartlett, op. cit., p. 159, quotes Tarnier. 

14 Coutts, Infantile Syphilis, Lancet, vol. i, 1896, p. 971. 

lsVedder, E. B., Syphilis and Public Health, Philadelphia and New York, Lea 
and Febiger, 1918, p. 144, quotes Pileur. 
16 Fournier, A., Syphilis et Manage, Paris, G. Masson, 1880, p. 73. 



120 SYPHILIS OF THE INNOCENT 

syphilitic. Our figures are not entirely comparable with 
others that have been quoted which are often obtained in a 
gynecological or obstetrical clinic where only families of pa- 
tients with evidence of syphilis are considered or where other 
methods of selection are used. Figures given in the literature 
(Table 22) as to the amount of sterility occurring in 
syphilitic families vary from 4.1 per cent 1 to 75 per cent 2 with 
many intermediate percentages. 

Birth-rate. — In Table 19, we deal with the birth-rate and 
average number of living children per family. Here again 
this information is obtained from history, and therefore the 
percentages of the 555 families can be considered. Of these 
555 families, 352 families, or 63.4 per cent had living children. 
The average birth-rate per family was 2.05, and the average 
number of living children per family at the time of the in- 
vestigation was 1.62. For purposes of comparison, we give 
an average birth-rate of 3.8 for Rhode Island, taken from the 
United States Census report (Table 23) as typical for 
New England. This figure is almost twice that found in our 
group of syphilitic families. In other words, the number of 
children born in this group of syphilitic families is prac- 
tically one half of that found in the same type of population 
taken at random. It is thus obvious that syphilis plays a 
large part in the matter of race suicide. Louis Dublin 3 states 
that it requires an average of nearly four children per family 
to make a new generation as large as the old. The average 
of 2.05 births per family in our group of syphilitic families 
means a loss in population. 

Families Free from Syphilitic Defect. — Table 20 shows the 
number of families with syphilis in the spouse and defects 
as to children, and illustrates how few families among the 
syphilitic group are free from some defect or other which 
might be traced to syphilis. The compilation shows that 
only 44.5 per cent of these families gave no history of sterility, 
abortions, miscarriages, stillbirths, or syphilitic children. If 
dead children had been considered among the foregoing ill 

i Jamieson, loc. cit. 

2 Haskell, op. cit., page 892. 

3 Dublin, L., Birth Control, Social Hygiene, toI. Ti, no. 1, Jan., 1920, p. 7. 



THE FAMILY 



121 



results involving the second generation, the percentages of 
families free from defects as to children would be even lower. 
It is fair to assume that in some instances early pregnancies 
resulted in syphilitic children who died young. As we had no 
definite way of demonstrating this, we have left the possibility 
out of consideration entirely and assumed that the dead chil- 
dren were not syphilitic. Only 30.3 per cent of all the families 
were free both from defect in the production or nature of off- 
spring and from syphilis in the spouse. In other words, less 
than one third of our entire group of 555 families should be 
considered as definitely free from syphilis or defect possibly 
due to syphilis. 

Families with Accidents to Pregnancies. — The number of 
families with accidents to pregnancies is shown in Table 21. 
Of the 555 families, only 427 had any pregnancies. Of these 
427 families, abortions, miscarriages, or stillbirths occurred 
in 156 families, or 36.5 per cent. This means that more than 
one third of the women who became pregnant had abortions, 
miscarriages, or stillbirths. The number of pregnancies which 
resulted unfortunately, irrespective of the number of families 
in which they occurred is also of interest. 



Table 27. Accidents to Pregnancies and Average Pregnancies 
Per Family in Non-syphilitic Families 



SOUKCE8 


Children's Bureau 

Figures on 1491 

Married Mothers 

of Babies Born 

IN 1911 IN 

Johnstown, Pa. 1 


Jeans' Families 

Showing No 
Obvious Syphilis 2 


Harmon; Poor 
Families, Known 
Cases of Syphilis 
Excluded 3 




No. 


P. C. 


No. 


P. C. 


No. 


P. c. 


Total families 


1491 




200 




150 




Total pregnancies 


*5808 


100.0 


886 


100.0 


826 


100.0 


Total accidents to preg- 
nancies 


445 


7.7 


88 


9.9 


78 


9.4 


Average pregnancies per 
family 


3.88 




4.43 




5.50 





* There "were 63 plural births, hence total pregnancies here represent total 
issue plus abortions, miscarriages, and stillbirths. 
i Infant Mortality Series, loc. cit. 

2 Jeans and Butler, loc. cit. 

3 Harmon, op. cit., p. 149. 



122 



SYPHILIS OF THE INNOCENT 

Table Showing Percentage of Syphilis in 



Class 



-191 Families in Which Evert Living 
Member was Examined 



General 
Paresis 



Cerebro- 
spinal 
Syphilis 



Nervous I 

system not ' 

involved ! 



Total 



TABLE 28 



THE AMOUNT 



Total individuals examined 
Total individuals negative. . 
Total individuals doubtful. . 
Total individuals positive . . 



No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


302 


100.0 


21 


100.0 


58 


100.0 


381 


249 


82.5 


17 


81.0 


38 


65.5 


304 


7 


2.3 







2 


3.5 


9 


46 


15.2 


4 


19.0 


18 


31.0 


68 



P.C. 



100.0 

79.8 

2.4 

17.8 



Percentage of Accidents to Pregnancies.— Table 24 presents 
the number of abortions, miscarriages, and stillbirths, com- 
pared to the total number of pregnancies. In the entire group 
of families (555) there were 1432 pregnancies. Two hundred 
and ninety-seven, or 20.7 per cent of these pregnancies re- 
sulted in abortions, miscarriages, or stillbirths. Of course, 
all the accidents to pregnancies in these families were not 
due to syphilis, as they occur not infrequently in non-syphil- 
itic families. Jeans 1 (Table 27) in an analysis of 200 families 
showing no obvious signs of syphilis, found accidents to 
pregnancies occurring in 9.9 per cent of a total of 886 preg- 
nancies. Harmon 2 states that in 150 poor families, exclusive 
of any known cases of syphilis, there were 826 pregnancies, 
with 78 or 9.4 per cent, resulting in a failure to produce a 
living child. In the Johnstown study 1491 married mothers 
had a total of 5808 pregnancies, which were unsuccessful in 
7.7 per cent of the cases. This seems to indicate rather 
definitely that accidents to pregnancies are about twice as 
frequent in the known syphilitic families as in those which 



1 Jeans and Butler, op. cit., p. 330. 

2 Harmon, loc. cit. 



THE FAMILY 



123 



Spouses and Children by Wassermann Survey 



B — 364 Families in Which One or More 

Members Besides the Patient 

Was Examined 



C — 555 Families, Total of A and B 



General 
Paresis 



Cerebro- 
spinal 
Syphilis 



Nervous 
system not 
involved 



Total 



General 
Paresis 



Cerebro- 
spinal 
Syphilis 



I Nervous 
system not 
1 involved 



Total 



OF SYPHILIS IN ALL INDIVIDUALS EXAMINED 



No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


No. 


P.C. 


217 


100.0 


59 


100.0 


101 


100.0 


377 


100.0 


519 


100.0 


80 


100.0 


159 


100.0 


758 


100.0 


161 


74.2 


52 


88.1 


73 


72.3 


286 


75.9 


410 


79.0 


69 


86.3 


111 


69.8 


590 


77.8 


4 


1.8 


2 


3.4 


1 


1.0 


7 


1.9 


11 


2.1 


2 


2.5 


3 


1.9 


16 


2.1 


52 


24.0 


o 


8.5 


27 


26.7 


84 


22.3 


98 


19.0 


91 11.2 


45 


28.3 


152 


20.1 



are considered in a routine procedure. The average number 
of pregnancies per family in our group of 555 families was 
2.58, which is distinctly lower than that given in the studies 
just mentioned. The average number of pregnancies per 
family in the study made by Jeans was 4.43; in that of Har- 
mon, 5.5; and in the Johnstown study, 3.88. 



Ratio of Stillbirths to Live Births. — Table 25 presents the 
ratio of stillbirths to live births. There were 40 stillbirths 
as compared with 1135 live births, giving a ratio of 3.52 
stillbirths to 100 live births. This ratio does not differ greatly 
from that obtained in community surveys. Thus, the average 
number of stillbirths per 100 live births for Boston, Massa- 
chusetts, in the years 1891-1919 inclusive is 3.79. The figure 
given by Dempsey 1 for Brockton, Massachusetts, is 3 still- 
births per 100 live births; for Johnstown, Pennsylvania, 4.5; 

i Dempsey, Infant Mortality: Results of a Field Study in Brockton, Massa- 
chusetts, Children's Bureau, United States Department of Labor, series no. 8, 
Bureau Pub., no. 37, p. 19. 



124 SYPHILIS OF THE INNOCENT 

for Manchester, New Hampshire, 4.8; for Saginaw, Michigan, 
3.3; for New Bedford, Massachusetts, 2.8; and the average for 
these five cities is 3.8. In other words, it would seem that 
there was no particular difference in the stillbirth ratio in 
the 555 syphilitic families from that found in the general 
community. We may therefore conclude that whereas the 
incidence of abortions and miscarriages is very much higher 
in our syphilitic group than in the general unselected groups 
of families, the incidence of stillbirths is approximately the 
same in both groups. 

Percentage of Syphilitic Individuals. — The number of 
syphilitic individuals found in the families of these syphil- 
itics has been shown for the mate and child separately. In 
Table 28 we give the figures for both combined. 

The incidence of the positive Wassermann reaction is 
shown to vary between 17.8 per cent (191 families) and 22.3 
per cent (364 families). Seven hundred and fifty-eight indi- 
viduals in all were examined. Of these, 20.1 per cent gave a 
positive Wassermann reaction, whereas 2.1 per cent gave a 
doubtful reaction. This would seem to represent fairly ac- 
curately for general purposes, in a routine series of mates 
and children of the late syphilitic patient, the number of in- 
dividuals who will give a positive or doubtful Wassermann 
reaction. 

Comparison of Families of Syphilitics with Different Mani- 
festations of the Disease. — In the discussion which has pre- 
ceded, no consideration has been given to differences occurring 
in the three divisions of syphilitic cases which we have 
offered, namely, general paresis, cerebrospinal syphilis, and 
syphilitic cases in which the central nervous system is not 
involved. This comparison is given in Table 29. 



THE FAMILY 



125 



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126 SYPHILIS OF THE INNOCENT 

This table indicates that there is only a slight difference in 
the proportion of difficulties that may be found in the three 
groups. The number of cerebrospinal syphilitics occurring in 
the families in which all were examined (191) is so small that 
this group is not valuable for this particular aspect of the 
study. Considering the other two groups (364 and 555), 
there are a few facts which stand out conspicuously. 

There is no one of these three types of syphilis that does 
not produce its effect upon the family. There is some differ- 
ence in the percentage figures given under the three groups. 
In a general way the Wassermann survey shows a smaller 
number of positive Wassermann reactions in the mates and 
children of the patients who had cerebrospinal syphilis, while 
on the other hand, more families in this group showed acci- 
dents to pregnancies. There is very little difference in the 
percentages obtained in the families of patients who had gen- 
eral paresis and those without involvement of the nervous 
system. The variation that does occur is apparently within 
the ordinary limits of variation of a finite group. It may 
therefore be stated that in a general way the difference in 
the effect of syphilis upon the mates and offspring of persons 
suffering from syphilis of the nervous system and of those suf- 
fering from syphilis which does not involve the nervous 
system is not sufficient to be of any great importance; the 
same types of difficulty occur with a frequency that does not 
greatly vary. The problems of syphilis from the familial 
standpoint are practically the same whatever course the 
syphilis may take in the individual patient. 

Importance of Methods of Selecting Families in Studies of 
Incidence. — Any marked difference between our figures and 
those reported in the literature is probably due to a conscious 
or unconscious selection in other studies. The discrepancies 
due to basing figures on a selected group are shown by a com- 
parison of the data of our unselected 555 families with that 
found in the selected group of 236 syphilitic mothers (see 
Chap. 3, page 56). Thus, in the 236 families with syphilitic 
mothers, 95, or 40.2 per cent were childless, as compared with 
29.7 per cent childless marriages in the entire 555 families. 
The amount of actual sterility did not yslyj greatly. Of the 



THE FAMILY 



127 



236 mothers, 24.5 per cent were sterile, as compared with 23 
per cent in the total group (555). On the other hand, 15.7 
per cent of the syphilitic women had abortions, miscarriages, 
or stillbirths, and no children born alive, as compared to 6.7 
per cent of the larger group (555). In the group composed of 
syphilitic mothers, the birth-rate was 1.84 and the average 
number of living children per family 1.33. In the entire 
group (555) the birth-rate was 2.05 and the average number 
of living children per family, 1.62. In the group of 236 fami- 
lies, 27.5 per cent of the children examined gave a positive 
Wassermann reaction as compared to the 12.8 per cent in the 
larger group of 555 families. The comparison throughout is 
given in tabular form: 

Table 30 





236 Families in 

Which the Mothek 

Gave a Positive 

Wassermann 
Reaction 


Total Group of 555 

Families in Which 

One or Both Parents 

Gave a Positive 

Wassermann 

Reaction (Includes 

Group op 236 

Families) 




No. 


P. C. 


No. 


P. C. 


Families with positive Wassermann 
reaction in children 


23 


9.7 


36 


6.5 


Families with no pregnancies 


58 


24.5 


128 


23.0 


Families with no children, but with 
abortions, miscarriages, and still- 
births 


37 


15.7 


37 


6.7 


Families with no children 


95 


40.2 


165 


29.7 


Families in which abortions, mis- 
carriages and stillbirths occurred 


93 


52.2 


156 


36.5 


Birth-rate 


1.84 




2.05 




Average number of living children 
per family 


1.33 




1.62 




Total pregnancies 


632 


100.0 


1432 


100 


Accidents to pregnancies 


198 


31.3 


297 


20.7 


Average number of pregnancie sper 
family 


2.68 




2.58 




Children examined 


142 


100.0 


423 


100.0 


Children positive 


39 


27.5 


54 


12.8 



128 SYPHILIS OF THE INNOCENT 

Summary of Familial Effects of Syphilis. — A summary of 
our findings in this study of a consecutive series of the families 
of late syphilitics shows : 

1. The family of the late syphilitic abounds with evidence of 
syphilitic damage. 

2. At least one fifth of the families of syphilitics have one or more 
syphilitic members in addition to the original patient. 

3. Between one third and one fourth of the families of syphilitics 
have never given birth to a living child. This is much larger than 
the percentage obtained from the study of a large group of New 
England families taken at random. Here it is shown that only one 
tenth were childless. 

4. More than one third of the families of syphilitics have accidents 
to pregnancies, namely, abortions, miscarriages, or stillbirths. 

5. The birth-rate in syphilitic families is 2.05 per family; whereas 
the birth-rate in the New England families mentioned above is 3.8 
per family or almost twice as high. 

6. Over one half of the families show defects as to children (steril- 
ity, accidents to pregnancies, and syphilitic children). 

7. Only one third of the families show no defect as to children or 
Wassermann reaction in spouse. 

8. About one fifth of the individuals examined show a positive 
Wassermann reaction ; more of these are spouses than children. 

9. Between one fourth and one third of the spouses examined show 
syphilitic involvement. 

10. Between one in twelve and one in six of the children examined 
show syphilitic involvement. 

11. One fifth of all children born alive in syphilitic families were 
dead at the time the families were examined. This does not differ 
materially from the general average in the community. 

12. One fifth of the pregnancies are abortions, miscarriages, or 
stillbirths, as compared with less than one tenth of the pregnancies in 
non-syphilitic families. 

13. The average number of pregnancies per family is 2.58 com- 
pared with 3.88, 4.43, and 5.51 in non-syphilitic families. 

14. There are 3.52 stillbirths per 100 live births in the syphilitic 
families, as compared with the 3.79 reported by the Massachusetts 
Census study of non-syphilitic families. This shows no very marked 
difference. 

15. A syphilitic is a syphilitic, whether his disease is general 
paresis, cerebrospinal syphilis, or visceral syphilis without involve- 
ment of the central nervous system, and the problems affecting his 
family are the same in any case. 



THE FAMILY 129 

Severe Effects of Familial Involvement. — The whole story 
of the effect of syphilis on the family cannot be told by 
statistics, although these indicate the great frequency with 
which syphilis acquired by an individual permeates his family. 
The toll of syphilis is enormous in some families; in others 
the amount of damage may be very slight. In fact, as has 
already been shown, in many instances a syphilitic does not 
infect his family. There are all gradations in the amount of 
involvement that may occur, from the families in which there 
is no familial infection to those in which every member shows 
definite syphilitic disease. 

Case 78. Sally McNutt. 

Father, Wasserraann reaction negative. 
Mother, Wassermann reaction positive. 

Pregnancies. 

1. Miscarriage, 2 months. 

2. Mary, juvenile paretic. 

3. Miscarriage, 3 months. 

4. Congenital syphilitic. 

5. Congenital syphilitic. 

6. 7, 8. Miscarriages. 

In this family both the father and mother denied venereal infec- 
tion but the examination of the mother gave definite evidence that 
she was syphilitic. There were eight pregnancies resulting in five mis- 
carriages and three syphilitic children, the oldest of whom at the age 
of 12 was in an advanced stage of juvenile paresis. The other two 
children were congenital syphilitics who may have serious difficulties 
later in life. 

Case 79. Syphilis was discovered in the Flynn family when the 
father of the family was in the forties. He had syphilis of the throat 
which led to his death. An examination of the family showed the 
following : 

Father, 40— Syphilitic throat. 

Mother, 42 — Syphilis (Wassermann positive) . 

Pregnancies. 

1. Son, 18 — Syphilis (Wassermann positive), epilepsy. 

2. Son, 16 — Syphilis (Wassermann positive). 

3. Son, 15 — Syphilis (Wassermann positive). 

4. Daughter, 10 — Syphilis (Wassermann positive). 



130 SYPHILIS OF THE INNOCENT 

5. Daughter, 8 — Wassermann doubtful. 

6. Son, 7 — Wassermann doubtful. 

7. Daughter, 5 — Wassermann negative. 

8. Daughter, 3 — Wassermann negative. 

Case 80. Mazzocca family. 
Father, alcoholic, dead. 
Mother, poor health, Wassermann positive. 

Pregnancies. 

1. Boy, dead, (11 months) diphtheria. 

2. Boy, dead, (18 months) scarlet fever. 

3. Boy, dead, (22 years) tuberculosis. 

4. Boy, dead, (20 years) pneumonia. 

5. Patient 18, juvenile paresis. 

6. Girl 16, syphilitic bone disease; interstitial keratitis. 

7. Stillbirth (8 months). 

8. Girl, dead, (14 months) meningitis. 

9. Miscarriage (3 months). 

The toll of syphilis in the Mazzocca family was a syphilitic mother 
whose nine pregnancies resulted in two living syphilitic children and 
seven who never came to term or who died after birth. 

Case 81. The history of the Jones family shows the destructive 
effects of syphilis on the progeny. The mother when about 41 years 
of age was put under treatment for syphilis. It was not possible 
to induce the father to have an examination. The results of the 
pregnancies are as follows : 

1. Stillbirth. 

2. Girl, 17, congenital syphilis, epilepsy, and feeble-mindedness. 

3. Boy, dead, (4 months). 

4. Boy, dead, (6 months) convulsions. 

5. Boy, dead, 2 days. 

6. Boy, 14, mental retardation, not examined for syphilis. 

7. Boy, 6, physical examination and Wassermann reaction 

negative. 

8. Boy, dead, (4 months). 

9. Girl, (8 months). Marked malnutrition; under treatment 

for congenital syphilis. 
The mother is again pregnant. 

Thus out of nine pregnancies there is only one child who is normal 
as far as known. 



THE FAMILY 



131 



Case 82. Moses Bornstein. 

Father. Syphilitic. 

Mother, 43 — Cerebrospinal syphilis. Died at 45. 

Pregnancies. 

1. Son, 19 — Juvenile paresis. Died at 23. 

2. Son, 17 — Ruptured aneurysm. Died at 20. 

3. Son, 16 — Achondroplasia. 

4. Son, 14 — Caries of the spine. 

5. Son, 11 — Stigmata of congenital syphilis. 

6. Infant, died shortly after birth. 

7. 8. Stillbirths. 



Case 83. John Friedreich. 



Familial Syphilis 



Father 

C? 

died 

of 

Syphilis 



Mother 

9 

Syphilitic 



after birth of first child husband 
contracted syphilis and infected wife. 



9 

dead 



miscarriage 
Case 84. Fred Klein. 



9 i <? 



dead miscarriage juvenile normal 

paretic 



Familial Syphilis 



Father 

C? 

syphilitic 



Mother 

9 

syphilitic 



congenital 

syphilitic 

dead 



juvenile 
paretic 



congenital 
syphilitic 



congenital 
syphilitic 



congenital 
syphilitic 



miscarriage 



Blaisdell 1 has studied 30 families selected to show the 
ravages of syphilis. " There were 132 definite pregnancies 
in these 30 families. These resulted in only 23 healthy chil- 

l Blaisdell, J. H., The Menace of Syphilis of To-day to the Family of To- 
morrow, Boston Medical and Surgical Journal, vol. clxxv, no. 1, July 6, 1916, 
pp. 7-13. 



132 SYPHILIS OF THE INNOCENT 

dren, the large majority of whom were born before infection 
entered the family. Of the 53 living children syphilis claims 
at least 24, or 45 per cent. In the cases of the 79 deaths syphilis 
may be credited as the probable causative factor in at least 
59, or 74 per cent. Totaling, syphilis scores in 83 out of 132 
pregnancies, or 62 per cent." These figures cannot be used 
as indicative of the percentage of syphilitica in any random 
group of families but simply represent the possibilities in a 
selected group. 

Cases of Milder Involvement. — The cases we have just 
presented illustrate how severely syphilis may involve the 
family. The involvement may be very much less but never- 
theless quite significant. 

Case 85. In the Wilton family the mother gives a history of a 
syphilitic infection. The first two pregnancies resulted in miscar- 
riages. The oldest living child at the age of 15 is a congenital syph- 
ilitic with syphilis of the central nervous system and blindness in one 
eye from an old interstitial keratitis. There was one stillbirth and 
two children had died, but there are four living children who are 
apparently well and not infected with syphilis. Thus, out of ten 
pregnancies, there are four healthy, apparently normal children. 

Case 86. Syphilis was diagnosed in Agnes Fairfax when she was 
33 years of age. An examination of the family showed that the hus- 
band was also syphilitic, as were the two oldest children of 8 and 6 
years. The two youngest children, who were 4 and 1, were not in- 
fected. There was no history of miscarriages or stillbirths in this 
family. Although four of the members showed evidence of syphilis, 
the difficulties that had arisen at the time when the case was seen had 
not been very great. 

Case 87. Murray Dalton acknowledged having syphilis some time 
prior to his marriage. His wife's first two pregnancies resulted in 
miscarriages. Following the miscarriages a child was born who was 
frail in infancy and had a spina bifida. At the age of five she de- 
veloped iritis. At 18 it was found that the Wassermann reaction was 
positive in her blood. The next child was hydrocephalic and mentally 
deficient. "When examined at the age of 16 his Wassermann reaction 
was negative in the blood. The next three children aged 12, 10, and 
5, respectively, at the time of their examination were apparently 



THE FAMILY 133 

perfectly healthy. The wife at this time showed no evidence of 
syphilis. In this family there were two miscarriages, a syphilitic 
child with a spina bifida, a feeble-minded child with hydrocephalus, 
and three normal healthy children. 

Case 88. John Corelli was a syphilitic who infected his wife. The 
infection did not seem to go further in this family, for there were 
three pregnancies which resulted in three children who were appar- 
ently quite free of syphilis. The amount of syphilitic involvement in 
this family considered as a unit of five members, is relatively small. 

Sterility. — One must consider as examples of rather severe 
familial involvement the families in which no children are born 
alive. These fall into two groups: first, the families which 
are completely sterile, apparently as a result of syphilis; and 
second, those in which pregnancies occur but do not come to 
term. Reference to the tables on pages 114-5 shows that 23 per 
cent of the families had no pregnancies whatever, while 6.7 
per cent had unsuccessful pregnancies, making a total of 
nearly 30 per cent of the families who were entirely without 
children. One must also consider here the families in which 
congenital syphilitics were born but lived only a short time so 
that after a few years the family again found itself childless 
as the result of syphilis. 

Case 89. Anna Mcintosh married when 19 years of age and ac- 
quired syphilis from her husband. Before marriage she was a strong 
healthy woman. During her married life she had four miscarriages 
but no children who reached term. 

Case 90. Tessie Gould was a syphilitic woman who had three mis- 
carriages during her five years of married life. Her husband died at 
the end of this time. There were no living children. 

Case 91. May McPherson and her husband were both syphilitic. 
One child was born alive but died at the age of a few months of con- 
vulsions. This child was probably syphilitic. At the time of its 
birth the mother had copper colored marks on her body and she and 
her husband were started on antisyphilitic treatment. Following the 
death of this infant she had four miscarriages with no living children. 

Case 92. Leo Guimazes was diagnosed as a case of general paresis 
at the age of 29. His wife, who was 27, was found to be syphilitic. 
The pregnancies were as follows: 1, premature stillbirth at 8 months; 
2, miscarriage at 7 months; 3, child born alive who died at 15 months; 



134 SYPHILIS OF THE INNOCEKT 

4, miscarriage at 3 months. Although there was one child born alive, 
at the time the family was broken up because of the commitment of the 
husband there were no living children. 

Not All Accidents to Pregnancies Caused by Syphilis. — It 
must always be borne in mind that there are various causes 
besides syphilis for abortions, miscarriages, and stillbirths. 
In many instances, a series of miscarriages or other accidents 
to pregnancies have occurred in families in which there was 
not the slightest evidence of syphilis. Prolapse of the uterus, 
congenital deformity, systemic diseases, acute infections, 
trauma, voluntary acts, and the like may cause one or a series 
of accidents to pregnancies. 

Case 93. Grace Truell was a woman of 45 who came to the hos- 
pital because of mental disease. There was no evidence of syphilis, 
either in herself or her husband. She had four miscarriages and one 
child who died at ten years of age. The history of the pregnancies 
is very similar to what one finds in syphilitic families but there is no 
evidence of syphilis in this family and it is in no way the cause of the 
miscarriages. 

Case 94. Mrs. Short was a neurasthenic woman who showed no 
evidence of syphilitic disease. She had two living children and had 
had four miscarriages, two of which were induced. 

No Familial Involvement. — It is always possible in a family 
in which only one of the parents is syphilitic that the disease 
has not been passed on to any of the other members. This 
occurs very frequently in those cases in which the male parent 
acquired his syphilis some years before marriage. When the 
female parent has had syphilis it is much more probable, as 
we have seen, that she will transmit syphilis to the children. 

Date of Entry of Syphilis. — Syphilis may enter the family 
at any time. Where the infection occurs after the birth of 
perfectly normal children the effects of syphilis are, by con- 
trast, all the more evident. Those children born before the 
parental infection, unless they happen to acquire syphilis by 
chance contact will be quite free of syphilis, whereas those 
born after the infection will probably be congenital syphil- 
itics or else such pregnancies as occur will never reach term. 



THE FAMILY 



135 



Case 95. In the Flint family there were five normal healthy chil- 
dren ranging* in age from 20 to 12. Directly after the birth of the 
last child, Mr. Flint acquired syphilis which he promptly transmitted 
to his wife. There were three pregnancies after the syphilitic infec- 
tion had entered the family, two resulting in stillbirths and one in a 
child who died at the end of 14 days. Thus, we see a couple whose 
fecundity was proved by the birth of five strong healthy children, but 
as soon as syphilis entered the family this fertility was destroyed and 
no healthv children were born. 



Father 

& 



Mother 

9 



Syphilis acquired by father 
and mother infected. 



& <? 9 9 9 

Normal Normal Normal Normal Normal 



Stillbirth Stillbirth 



Dead at 
14 days 



Case 96. In the Maguire family there were three healthy children. 
The father then acquired syphilis which he transmitted to the mother, 
who in turn infected the youngest child. The next pregnancy re- 
sulted in a child who lived but 6 weeks, the succeeding pregnancy in 
a child who showed signs of congenital syphilis, the next in a child 
who died at 5 years, and the final pregnancy in a stillbirth. The 
result of the entrance of syphilis in the family may be tabulated as 
follows : 

Father Mother 



<? 

normal 



9 

normal 



> Father acquired ; syphilis and infected wife. 



d 1 


o 


C? 




C? 






Normal 


Normal 


Normal at birth 


dead 


congeni- 


dead 


still- 






acquired syphilis 


at 


tal 


at 


birth 






from mother and 


6 


syphili- 


5 








developed cerebro- 


weeks 


tic 


years 








spinal syphilis 











136 SYPHILIS OF THE INNOCENT 

Different Effects of Syphilis on Different Members of 
Family. — When syphilis has entered and spread through the 
family its effects on the various members may be quite similar 
or quite different. We have already called attention to the 
Kassowitz law which states that there is a tendency for the 
virus to become weaker with time and that the children born 
later are likely to have milder forms of involvement than 
those born earlier, or indeed, may escape the infection entirely. 
There is, of course, no definite rule and as Fournier puts it, 
"Each person makes his syphilis according to his image — the 
soil is more important than the seed. ' ' 

Case 97. The different effects that syphilis produces on members of 
a family are shown by the Tennyson family. The mother had latent 
syphilis. The father was dead, cause unknown. The two older chil- 
dren, aged 16 and 9, were apparently healthy. The third child, a girl, 
aged 8, had certain mild stigmata of congenital syphilis and a strongly 
positive Wassermann reaction. Her younger sister aged 6y 2 was 
also a congenital syphilitic who had involvement of the central ner- 
vous system the symptoms of which made their appearance follow- 
ing a fall at the age of 5. She had deteriorated mentally and had a 
spastic paraplegia. A younger brother aged 4 was apparently well 
and had a negative Wassermann reaction, and the youngest child died 
at the age of 9 weeks. 

Case 98. There were two children in the Sanzi family. The elder 
was a girl of six who showed a positive Wassermann reaction as the 
only symptom of her syphilis. A young brother aged 4 was a 
restless whining idiot, whose condition was very probably the result 
of his congenital syphilis. In this case the younger child was much 
more seriously damaged by the syphilis than his older sister. 

Same Effects an Different Members. — Modern experience 
and experimentation give evidence that there are strains of 
spirochetes which seem to have predilections for certain 
tissues. This shows up most plainly in cases of central 
nervous system involvement. There are numerous instances 
where mother, father, and children all show central nervous 
system syphilis. 

Case 99. The Rossini family is especially instructive in showing 
the tendency of syphilis to infect the central nervous system of differ- 



THE FAMILY 137 

ent individuals in the same family. The fact that Mr. Rossini de- 
veloped the symptoms of general paresis at the age of 33, first brought 
this family into consideration as syphilitic. His wife, who was 29 
years of age, had definite evidence of syphilis of the central nervous 
system as shown by the physical symptoms and laboratory tests. 
There had been seven pregnancies and there were seven living chil- 
dren. The oldest, Mary, was 13 years of age at the time that syphilis 
was discovered in the family. She had a positive blood and spinal 
fluid showing an involvement of the central nervous system. She was 
feeble-minded, rating 6 years and 8 months on the psychometric scale 
while her actual age was 12. The second child was seen when he was 
10 years of age. His blood and spinal fluid were both negative and 
he rated 8 years and 8 months. He was a very difficult child and was 
sent to a reform school for truancy. The third child at 8 had a posi- 
tive Wassermann reaction in the blood but his spinal fluid was nega- 
tive except for a very mild change in the gold reaction. The fourth 
child also had a positive blood Wassermann and his spinal fluid 
showed a moderately positive syphilitic gold reaction but otherwise 
was negative. He was committed to a school for the feeble-minded. 
The next two children had negative blood Wassermann reactions; 
the spinal fluid was not examined. They seemed to be fairly bright 
children. The last child was a baby of 8 months who was not ex- 
amined. In this family both the father and mother had definite 
neurosyphilis. The oldest child showed involvement of the central 
nervous system, the following child apparently escaped involvement 
while the next two children showed some evidence of involvement of 
the nervous system as far as could be proved by the colloidal gold test. 

Case 100. Gridley Ringer was brought to the clinic at the age of 
15 because he could not get along in school and was obviously de- 
mented. An examination showed definite evidence of congenital 
syphilis. He had a characteristic Olympic brow, Hutchinsonian teeth, 
and the scars of old rhagades at the corners of his mouth. He showed 
a high degree of dementia and his blood and spinal fluid gave the 
characteristic tests of paresis. The history showed that his birth 
was preceded by two miscarriages, one of which was induced and the 
other spontaneous. During his infancy he was troubled a great deal 
with ' ' eczema. ' ' Shortly after being seen he had a number of shocks 
which finally led to his death at the age of 15. The father acknowl- 
edged a syphilitic infection 26 years previously, that is, about ten 
years before the birth of the child. He said, however, "It did not 
get into my system. I have been perfectly well ever since." Ques- 
tioning, however, disclosed the fact that he had been suffering with 



138 SYPHILIS OF THE INNOCENT 

" rheumatism ' ' for the past six months. A physical examination con- 
firmed by the laboratory tests brought to light that he had locomotor 
ataxia. His wife, the mother of Gridley, said she was in perfectly 
good health. Her one complaint was deafness. An examination 
showed that she was suffering from a disease of the auditory nerve. 
It was almost certain that this was the result of the syphilitic infec- 
tion. In this family, then, we have three members, all of whom showed 
disorder of the nervous system as a result of syphilis. 

Necessity of Familial Examination. — The damage done to 
the families of syphilitics has been demonstrated above statis- 
tically and by illustrative cases. The only way of finding 
whether syphilis is present is to examine the various members 
of the family for evidence of acquired or congenital syphilis. 
This means that when a syphilitic patient is discovered, 
whether he is in an early or late stage, the examination of all 
the other members of the family — husband and wife, and in 
the case of a congenital syphilitic, brothers and sisters — is 
indicated. 

Examination Discloses Active Syphilis. — The chief reason 
for examining the family is to find out if anyone else besides 
the patient is suffering from active syphilis and is in urgent 
need of treatment for his own sake as well as for others. Not 
only when the parent has a recent syphilis is there danger of 
familial infection by intercourse or contact, but also when a 
mature son or daughter living in close family communion 
acquires syphilis. Here family examination is advisable to 
discover cases of infection spread by accidental contact such 
as is likely to occur in family life. A typical case of such 
spread is Case 68 (Chap. 3, page 87), where the younger 
brother was probably infected by sleeping in the same bed 
with his syphilitic older brother. The brother was treated 
but no family examination was made and the young brother's 
infection was not discovered until he had developed a fatal 
syphilitic disease. 

Examination Discloses Latent Syphilis. — Next in impor- 
tance in the family examination is the discovery of latent un- 
suspected syphilis. The syphilitic arrives at a clinic anywhere 



THE FAMILY 139 

from a few days to many years after infection, and often mem- 
bers of the family are syphilitic although they are not aware 
of it. Examination affords the opportunity of giving warning* 
of future dangers and of instituting immediate treatment. 

Case 101. Giuseppe Nigro, aged 75, thought he was worth a million 
dollars, threatened the life of his wife and children, and caused diffi- 
culty in a general hospital where he was brought for treatment. He 
was found to be suffering from tabo-paresis and was committed to a 
state hospital where he died in a short time. He acknowledged syph- 
ilis of many years duration for which he had had no treatment. On 
account of language difficulty and his mental condition, he gave very 
little family history. At this period there was no follow-up of syph- 
ilitic cases at the hospital and no examination of the family was 
made. Three years later, the patient's daughter was admitted to the 
hospital in a confused and deluded state, a condition precipitated 
by influenza, but which probably occurred on the basis of con- 
genital syphilis. She showed very characteristic features, including 
Hutchinsonian teeth, on which a definite diagnosis of congenital 
syphilis could be made. Her blood Wassermann reaction was positive. 
Examination of the mother showed that she likewise was syphilitic. 
Treatment of both mother and daughter was instituted. In the course 
of a few months the girl had recovered as far as her mental symptoms 
were concerned and she was able to take up her work in the com- 
munity. After a short time she married and became pregnant. If 
the family had been followed up and examined three years previously 
when the father was found to have syphilis, treatment could have 
been undertaken at that time, and it is quite possible that the daugh- 
ter 's difficulty might have been avoided. 

Case 102. Patrick O'Halloran came to the hospital because of an 
alcoholic debauch ending in delirium tremens. In a routine examina- 
tion it was found that he was syphilitic and for this reason his family 
was brought into the hospital for examination. The wife showed no 
evidence of syphilis, but the oldest son, 17 years of age, had a posi- 
tive Wasserniann reaction and there was a history that he had had 
some eye difficulty when he was a youngster which it seemed prob- 
able was interstitial keratitis. Under the circumstances, treatment was 
urged for Patrick, Jr. but the idea was scouted by the parents as well 
as by himself. It was insisted that he was quite well and that there 
could be nothing the matter with him, so the case was lost by default. 
Six years later we again ran across Patrick at the age of 23. He was 



140 SYPHILIS OF THE INNOCENT 

almost completely deaf, due to bilateral lesions of the auditory nerve. 
This condition had been progressive for the past four years and only 
at the time when he became almost completely deaf was the much 
needed antisyphilitic therapy begun. It is quite probable that had 
treatment been instituted six years previously, that is before the 
beginning of the changes in his auditory nerves, his deafness might 
have been prevented. The family examination disclosed the problem 
but lack of the patient's cooperation prevented anything from being 
done. A case of this sort shows the value of treating congenital syph- 
ilitics even though symptom-free. It further indicates the value of 
making strenuous efforts to overcome the uncooperative attitude of 
some individuals. 

Incidence of Unsuspected Syphilis Disclosed by Examina- 
tion. — The value of examining families of known syphilitics 
to discover the unsuspected cases is shown by the following 
study of 100 families in which at least one other member 
besides the original patient was syphilitic. 

No. p. c. 
Eelatives with syphilis diagnosed at Psychopathic 

Hospital through family examination 112 72.7 

Relatives with syphilis diagnosed elsewhere 42 27.3 

Total syphilitic relatives 154 100 . 

Of the 112 diagnosed at the Psychopathic 

Hospital 112 100.0 

Fathers 

Symptom free 18 

Tabetics 2 

Neurosyphilitics 2 

22 19.6 

Mothers 

Symptom free 47 

General paretics 1 

Neurosyphilitics (not tabetics) .... 3 
Other symptoms 2 

53 47.4 

Children 

Symptom free 28 

Neurosyphilitics 1 

Defect in sight 3 

Defect in hearing 1 

Other symptoms 4 

37 33.0 



THE FAMILY 141 

No. P. C. 

Of those diagnosed elsewhere 42 100 . 

Fathers 

Symptom free 8 19.0 

Mothers 

Symptom free 11 

General paretics 1 

12 28.6 

Children 

Symptom free 20 

Defect in sight 2 

22 52.4 

It is especially significant to note that of the 154 who were 
found to be syphilitic, 72.7 per cent had no idea of their 
syphilis until it was discovered as a result of the family 
examination. The greater percentage of these patients (83 
per cent) were in a stage of syphilis in which they were not 
suffering from any definite symptoms, which of course, is a 
favorable time to make a diagnosis. 

A complete examination of the entire family has the 
advantage of giving a clean bill of health to the uninfected. 
Often the wife of a syphilitic patient is cognizant of the pos- 
sibility of infection and it is only fair to her to confirm or 
disprove this idea as soon as possible. Moreover in the case 
of some future disease it will be a great aid to the physician 
to have this information at hand. 

Methods of Examination; History. — The methods of dis- 
covery of familial syphilis are the same as those employed in 
the detection of the infection in the individual, discussed in 
the previous chapter. The examination is incomplete with- 
out a history of the individual and the family, physical ex- 
aminations, and tests on the blood and spinal fluid. In spite 
of the value and importance of a history one must be very 
cautious of drawing any very far-reaching conclusions from 
some histories given by the patient or relative who may be 
consciously prevaricating or may not know the true facts. 

Case 103. An example of the inaccuracy of histories is given by 
the case of Mrs. Price who developed general paresis at the age of 40. 
The husband gave a history that the patient's father had contracted 
syphilis and infected his wife. We might draw the conclusion that 
the patient was a congenital syphilitic. The husband denied any his- 



142 SYPHILIS OF THE INNOCENT 

tory of syphilis on his own part. The examination showed that he 
had a positive Wassermann reaction as did the only living son. As 
a matter of fact, the mother was not a congenital syphilitic and the 
husband 's history was in no way reliable. 

Clinical Examination and Wassermann Test. — The clinical 
examination is of the utmost importance and cannot be super- 
seded by the Wassermann test alone. The Wassermann test, 
however, is of the greatest service and if properly performed, 
controlled, and interpreted, is an essential. When the Wasser- 
mann test is performed routinely in hospitals, prisons, reform 
schools, other institutions, and private practice, it aids in 
picking out cases that might otherwise be unsuspected and 
thus makes for early and preventive treatment. 

A knowledge of the limitations of the Wassermann reaction 
is most important if "one is going to do justice to the test. It 
must be recognized in the first place that many syphilitics 
give negative Wassermann reactions. For example, early 
syphilitics often have negative W^assermann reactions. About 
40 per cent of the cases of tabes have negative Wassermann 
reactions in the blood. It follows, therefore, that one must 
not rule out syphilis merely upon a negative result of a Was- 
sermann test. Before accepting a positive Wassermann re- 
action as evidence of syphilis it should be confirmed either by 
definite clinical findings or by a repetition of the test with 
similar results. Statistics based upon the Wassermann test 
are accurate within the limits of the test. As we have noted, 
the false negatives and false positives tend to correct each 
other, and often where these corrections are not absolute, the 
relative results are sufficiently correct for purposes of com- 
parison. However, in dealing with an individual the matter 
is entirely different because in this case any error means an 
error of 100 per cent for the particular person. If the clinical 
evidence is sufficiently strong, one may make the diagnosis of 
syphilis in spite of a negative reaction. 

Case 104. 1 The value of the routine Wassermann both for the pa- 
tient and for the discovery of familial syphilis is well illustrated in the 
case of Janet Gibbons. At the age of 6 she developed a syphilitic 

l Children 's Hospital, Boston. 



THE FAMILY 143 

nasopharyngitis and interstitial keratitis. At this time the mother 
was examined and also found to be syphilitic. Delving into the his- 
tory of the case it was found that the child had been at the hospital 
five years previously when a diagnosis of osseous tuberculosis had 
been made. At that time a routine Wassermann test was not the rale 
and as she had no definite evidence of syphilis this diagnosis had not 
been made. If her condition had been discovered at that time by 
means of the Wassermann reaction, as it undoubtedly would have 
been, had routine Wassermann tests been in force, treatment might 
then have been instituted and the later difficulties perhaps prevented. 

Case 105. A negative Wassermann test on the blood must often be 
supplemented by a test of the spinal fluid. Mrs. Gulesian was the 
wife of a syphilitic. The routine Wassermann test was negative but 
she complained of a loss of memory, feeling weak, etc. A lumbar 
puncture resulting in positive findings showed that she was suffering 
from an unsuspected syphilis of the nervous system. 

Case 106. One may be led astray if he depends upon the results 
of the Wassermann reaction. Harry Congiano was a deaf-mute boy 
4% years of age. His Wassermann reaction was reported as positive. 
There were no other signs or symptoms that were definitely syphilitic. 
An examination of the cerebrospinal fluid showed that it was entirely 
negative. The Wassermann reaction was repeated on several instances 
and always found to be negative. The mother was also examined. She 
showed no signs or symptoms of syphilis and her Wassermann reaction 
was negative on two occasions. It seems that there can be very little 
doubt that the report of a positive Wassermann reaction on Harry 
was a mistake. 

Case 107. A similar false positive Wassermann reaction is shown 
in the case of Mrs. Davis's child. Mrs. Davis was brought to the hos- 
pital because of fainting spells. Her Wassermann reaction was re- 
ported as doubtful. Almost simultaneously her fourth child, a girl 
of 12, came to the out-patient department. She was a poorly nourished 
child who had never been very healthy. Her Wassermann reaction 
on the blood was positive. The doubtful reaction in the case of the 
mother and the positive reaction in the case of the child, along with 
the other symptoms, led one to suspect syphilitic involvement. It 
should be noted, however, that none of the other symptoms were 
definitely syphilitic or sufficiently suggestive in themselves to allow 
a diagnosis of syphilis to be made. The history of this case was en- 
tirely negative as far as syphilis was concerned. There had been six 
pregnancies, all terminating successfully, the last one resulting 



144 SYPHILIS OF THE INNOCENT 

in twins. All the children were living and ranged in age from 19 
years to one year. With the exception of the oldest boy, who was 
living away from home, they were all examined. They showed nothing 
suggestive of syphilis and had negative Wassermann reactions. The 
same was true of the father. The examination of the mother's cere- 
brospinal fluid was entirely negative as was the Wassermann reac- 
tion in the blood on repetition. Several further Wassermann tests 
on Anna were also negative. We must assume that the positive Was- 
sermann reaction originally obtained was due to some error. 

All doubtful tests should be repeated, as the following case 
indicates : 

Case 108. Three-year-old Pierre Nevers was examined as one of the 
children of a syphilitic. He was symptom-free except for a doubtful 
Wassermann reaction. The oldest child had a negative reaction and 
the second child was doubtful. Although the effort was made to re- 
peat the tests the mother proved uncooperative and the case was 
dropped. Five years later the mother brought Pierre in for anti- 
syphilitic treatment, a positive Wassermann reaction having been 
obtained at another hospital. Thus five years of possibly valuable 
treatment were lost through the delay in diagnosis. 

At times it is very difficult to get a consistent result with 
the Wassermann test. 

Case 109. The following series of tests on husband and wife show 
how difficult it may be to draw any conclusions. (Angelo family.) 

1 2 3 4 5 6 7 8 9 10 11 12 13 
Woman aged 27 1 * — — — I ? + + — + — =• 
Husband, aged 34 ? ? ? ? ? — — ? — — — 

* Unsatisfactory. 

Case 110. Julia Wilson was 6 years of age when first examined. 
Her father was a general paretic. Examination of the mother showed 
no signs of syphilis. Her Wassermann reaction was negative. Julia 
was not a very strong healthy child but did not show any definite 
syphilitic symptoms. The first Wassermann test was negative and 
the second one was positive. Several others in the following two years 
were negative. She had a sister, Ethel, one year her junior, who again 
showed no definite symptoms of syphilis. Her first Wassermann re- 
action was positive, a repetition was doubtful, and the succeeding tests 
were negative. 



THE FAMILY 145 

Provocative Treatment. — At times a syphilitic patient who 
gives a negative Wassermann reaction may show a positive 
reaction after treatment with arsphenamin. Treatment given 
for this purpose is known as provocative treatment and the 
reaction is spoken of as a provoked reaction. 

Case 111. Florence Jones developed interstitial keratitis at the 
age of 8 and had a positive Wassermann reaction. Her mother was 
examined and showed no definite evidence of syphilis and had a nega- 
tive Wassermann reaction. Nevertheless, it was felt that she prob- 
ably was syphilitic. She was given a provocative treatment and her 
Wassermann reaction became positive. 

Objections to Familial Examination — Technique of Secur- 
ing- Examination. — One of the objections that is often offered 
to the examination of other members of the family is that 
the discovery of syphilis in the family is likely to lead to 
marital discord. The remark is made over and over again 
that it is very dangerous because if a woman learns that her 
husband has syphilis the family will be broken up. In our 
seven years of experience we have found that this is not 
true. In many instances it is not even necessary to make it 
entirely clear what the trouble is in which one is interested. 
If syphilis is not found in the relative it is perfectly reason- 
able not to discuss the matter further. If syphilis is found, 
of course, it is essential to come out clearly and distinctly 
with the facts. However, by putting the discussion upon a 
medical basis and giving the individuals a proper understand- 
ing of the facts, family discord can be avoided. The only 
situation where there need be any worry in this regard is in 
those families in which the mate is on the point of separation 
and is only looking for some excuse to take the case to court. 
In such instances silence and avoidance of the possibility of 
becoming involved in the family difficulties is probably the 
part of discretion. ' 

When the family must be told that one is looking for 
syphilis or the patient must be notified that he is syphilitic, 
the question that constantly recurs is whether or not the 
social worker should break the news. It is our feeling that 
only in exceptional cases should anyone but the doctor actually 



146 SYPHILIS OF THE IXXOCENT 

in charge of the case take this upon himself. It is the doctor's 
privilege and duty to inform a patient about his disease 
whether it be tuberculosis, nephritis, or syphilis, and in most 
cases no one can do this as well as the doctor whom the patient 
considers especially versed in the handling of disease. On 
the other hand, there are many instances where the contact 
between the social worker and the patient is so close and the 
latter has so much confidence and regard for the worker that 
it can best be discussed by the patient and social worker. It 
may be advisable for the social worker to give this informa- 
tion when a syphilitic patient or relative refuses to come to 
the clinic and talk with the doctor. This, however, should 
not be the general rule, but should apply only to those excep- 
tional cases in which, in the opinion of both the doctor and 
social worker, it is advisable. In many cases, after the doctor 
has explained the condition to the patient and family, the 
social worker can be of the utmost assistance in completing 
the understanding of what the doctor has already said. Such 
a service on the part of the social worker is often more effec- 
tive than would be the unaided effort of the doctor. 

Experience has proved that in family examination the 
assistance of a well-organized social service department is 
essential. Any deviation from absolute systematic endeavor 
is almost valueless, and haphazard methods will result in 
failure to discover a large number of syphilitics. 

Typical Machinery for Examination at Boston Psycho- 
pathic Hospital — Difficulties and their Solutions. — The proper 
facilities and machinery for family examination are offered 
by many clinics and hospitals to-day. At our clinic at the 
Boston Psychopathic Hospital, the members of the family of 
every syphilitic patient who comes to the hospital or to 
the out-patient department are asked to report for examina- 
tion, and if it is considered necessary, for treatment. It 
makes no difference whether the original patient is in a con- 
tagious state or not, whether he is in the early or late phases 
of the disease, or whether he is a congenital syphilitic. Of 
course, the examination of the families of syphilitics should 
be made immediate]y after the infection. Unfortunately this 



THE FAMILY 147 

is done all too infrequently so that even though a patient is 
seen many years after his infection and in a state which is 
no longer contagious, it must be remembered that he may 
have been married at the time when he was very contagious. 
The work in cooperative cases is simple. Many clinic patients, 
however, are ignorant and poorly informed. Neither they nor 
their relatives understand the significance of the disease or 
see any relation between the disease of the patient and the 
examination of his family. The task of educating the family 
to the point of allowing the examination is often hampered 
by language difficulties. If the difficulty is due to lack of 
information it is important that the family be told why the 
examination is desired. Other individuals are irresponsible 
and though well understanding the significance of the ex- 
amination do not care to know whether they are infected or 
not. 

Very often those families who offer the most difficulty at 
the start, with a sufficient amount of persistence become the 
most cooperative. 

Case 112. Robert Clairinont came to the out-patient department 
when he was 13 years of age, because he was nervous, unmanageable, 
irritable, and was not getting along well in school. Examination 
showed that he was a congenital syphilitic. Treatment was pre- 
scribed for Robert and the mother cooperated with this suggestion. 
When it came to the examination of herself and the other children she 
refused. She said that they were healthy and that there was no need 
to examine them. Unfortunately she was not only ignorant but was 
also bad-tempered and pugnacious. On account of her ignorance it 
was not possible to go into frank detail as to the real situation. Syph- 
ilis would have meant only a reflection on the morality of herself and 
her husband, and as we found out later, argument with her would 
have had little avail. It was therefore necessary to compromise and 
get Robert well started on treatment ; finally, after sufficient time, it 
became possible to induce the mother to be examined. 

A rather interesting experiment was made in St. Louis as 
early as 1914 by Dr. Jeans 1 of the Children's Hospital, in an 
endeavor to examine uncooperative families. The support of 

l Jeans and Butler, op. cit., p. 329. 



148 SYPHILIS OF THE INNOCENT 

the juvenile court was enlisted to such a degree that in the 
uncooperative cases, if one child was a congenital syphilitic, 
the family was brought before the court who urged the parents 
to have the rest of the children examined. The court had 
no legal power to enforce examination, but this was rarely 
understood by the family. This procedure seems to have 
worked well in this one locality but it could hardly be recom- 
mended to other districts, for when a person is symptom- 
free and not in a contagious state he is likely to realize the 
lack of power of any court to enforce an examination. Of 
course, the influence of the court is likely to be more effective 
than that of the social worker and doctor in showing a 
recalcitrant person that an examination is really considered 
important. 

Circumstances in the family may make it very difficult for 
members to report to the clinic for examination. They may 
live a great distance and be unwilling to take the time or go 
to the expense of reporting. The family may be large and a 
mother may be unable to bring children or have no one with 
whom to leave them at home. A man or woman may be 
unable to leave work in order to come to the clinic. 

There are various ways in which most of these difficulties 
may be overcome. Where the doctor is interested and uses 
his authority and persuasive powers and where the social 
worker is willing to put effort and ingenuity into urging her 
cases to report, results are usually fairly good. An early 
morning clinic or an evening clinic for working people helps 
solve the difficulty that arises from the loss of time as does 
the more modern attitude of employers who show a willing- 
ness to allow their employees to take time off for medical care. 

The following table shows the success at the Psychopathic 
Hospital in following for examination the family of every 
syphilitic. It is seen that in 74.3 per cent of the families some 
member reported. Of the total relatives desired for examina- 
tion 78 per cent reported to the clinic. 



THE FAMILY 149 

Table 31. Families— 1916 to 1919 

No. P. C. 

Families desired for examination 460 100 . 

Reported 342 74.3 

Failed to report 118 25 . 7 

Relatives 

Relatives desired for examination 935 100 . 

Examined 632 67.6 

Came but examination not advised 99 10.6 

Unable to report, good reason 90 9.6 

Refused examination 23 2.5 

Not located 91 9.7 

Comparison of Difficulties of Family Examination by 
Private Doctor or Clinic. — The difficulty of family examina- 
tion is probably much greater for the private than for the 
clinic physician. The doctor often fears that if he presses 
the point of family examination against the wishes of his 
patient the latter will be so antagonized that he himself stops 
his much needed treatment. Further, there is the feeling 
that to a certain extent the private patient's relationship to 
the doctor is a business one. He pays the doctor to render 
certain service which does not include treating the family 
and because he does pay he feels that he has certain rights 
and privileges. On the other hand, the clinic patient pays 
little or nothing and the doctor need have no compunction 
about going into the family to find more patients for whose 
treatment he is to receive no recompense. In addition, the 
private doctor rarely has the facilities for follow-up such as 
are offered in a hospital clinic and social service department. 

And the most important deterrent of all is the question of 
medical secrecy. That information obtained by a physician 
in his professional capacity is a secret not to be divulged is 
shown in the oath of Hippocrates, formerly administered to 
all physicians: 

Whatever in connection with my professional practice or not in con- 
nection with it I see or hear in the life of men which onght not to be 
spoken of abroad, I will not divulge as reckoning that all such should 
be kept secret. "While I continue to keep this oath unviolated, may it 
be granted to me to enjoy life and the practice of the art respected 
by all men in all times, but should I trespass and violate this oath, 
may the reverse be my lot. 



150 SYPHILIS OF THE INNOCENT 

These difficulties of the private doctor seem to be a recom- 
mendation in favor of state medicine so that the well-to-do 
may get as good service as the poor. 

Necessity of "Follow-Up" for Treatment Cases. — After a 
person is brought to the clinic for examination and found to 
be syphilitic, results can be obtained only after a considerable 
course of treatment. Many years of experience have shown 
that syphilitic patients are usually prone to discontinue treat- 
ment before they are cured unless steps are taken to insist 
on their return to the clinic. Here again, the efforts of the 
social worker through a follow-up system are invaluable. 
The past inadequacy of treatment without such a system is 
shown by Blaisdell's study 1 at the Boston Dispensary before 
a follow-up system was established. Four hundred and fifty- 
one new cases (July 1913- June 1914) were studied. One hun- 
dred and sixty-four were primary or early secondary cases, 
136 secondary, 107 late, and 44 congenital. Twenty-eight per 
cent came but once ; 70 per cent came less than five times, an 
insufficient number of times to relieve even the presenting 
symptoms; only 9 per cent came more than eight times. The 
attendance of these 451 patients was analyzed to see how 
many visits would have been required for good treatment. It 
was found that as a group they actually paid only 29.4 per 
cent of the necessary visits for minimum good treatment. 

A study 2 of the Boston City Hospital Clinic in 1919 before 
and after a follow-up system was instituted is self-ex- 
planatory : 

A small preliminary study was made of the records of the patients 
with a diagnosis of syphilis who attended the clinic from March, 1918, 
to September, 1918, with a view of determining' the regularity of at- 
tendance. It was found that 116 patients in all attended the clinic 
during this time, 24 reportable (first and second stages) and 92 non- 
reportable (tertiary) cases; that 20 per cent had made only one visit, 
and that 80 per cent had not received adequate treatment, having 
dropped out after the fifth visit. 

i Blaisdell, J. H. The Menace of Syphilis to the Clean Living Public. Boston 
Medical and Surgical Journal, vol. clxxii, no. 4, April 1, 1915, pp. 476-483. 

2 Department of Medical Social Work, Boston City Hospital, Feb. 1, 1918- 
Jan. 31, 1919, Boston. 



THE FAMILY 151 

A simple follow-up system was then started by means of which 
every syphilis patient was kept track of. At the end of five months, 
a second study was made of the group attending the clinic from Sep- 
tember 1, 1918, to January 30, 1919, with the following results: 

Number of Syphilis Patients in Clinic 181 

Keportable Cases (Infectious) 59 

Non-reportable k ( Non-infectious) 122 

Of these 13, or 7 per cent had made one visit only; 32, or 18 per 
cent had dropped out after making five visits. The remaining 135, 
or 75 per cent were under treatment, while 14 per cent had been 
transferred to night clinics or other state clinics, and were reported 
as under treatment. 

The contrast of the 75 per cent under active treatment as against 
the 80 per cent who failed to receive adequate treatment sufficiently 
demonstrates the value of a medical social follow-up system. 

A more recent investigation 1 in New York City of 14 institu- 
tions treating venereal diseases shows that the follow-up of 
patients for treatment is still inadequate in spite of its well- 
known necessity. The sanitary code in New York requires 
a follow-up system. However, five of the 14 clinics had no 
follow-up at all, six used postal cards to some extent, and only 
three institutions were assisted by social workers in finding 
the cases who failed to respond to letter. As a result of this 
inadequate follow-up, the duration of treatment is shortened. 
In over 57 per cent of the records chosen at random, the 
patients had been under treatment less than six months and 
only 19.8 per cent had had treatment for more than a year. 
Half of the patients had made less than 14 visits to the clinic. 
A further indication of inadequacy of attendance is in the 
records. There was no mention of patients discharged. All 
patients, even Wassermann negative cases had left before a 
formal discharge. 

At the meeting of the All- America Conference on Venereal 
Diseases, in Washington, December, 1920, it was definitely 
stated that a follow-up system and social w r orker were essen- 
tials of every modern, well-run, syphilitic clinic. 

i Lewinski-Corwin, E. H., Venereal Disease Clinics, Social Hygiene, vol. 6, 
no. 3, July, 1920, p. 341. 



152 SYPHILIS OF THE INNOCENT 

Difficulties of ' 'Follow-up" for Treatment — Solutions. — 

There are attendant difficulties in a follow-up system for 
treatment, similar to those mentioned under family examina- 
tion. Often there seems to be a likelihood that a contagious 
case will not receive treatment. Here the social worker can 
often be the means of forcing treatment, thereby reducing the 
chances of innocent familial syphilis. 

Case 113. The Massachusetts General Hospital 1 reports the case 
of a 9-year old girl who comes to the hospital with an accidental 
primary lesion of syphilis on the lip, the source of infection being 
unknown. The family had previously been known to the clinic when 
a boy of 13 had interstitial keratitis, and the mother a positive blood 
Wassermann. At the time an effort was made to treat these two 
members of the family, but there was absolutely no cooperation. The 
little girl had not then acquired syphilis. In view of the past ex- 
perience with the family and because the mother failed to carry out 
her part, the case was taken to court and the child was forced to re- 
port to the clinic. Without the medical social worker this child would 
probably never have received adequate treatment. 

A contagious patient often gives the wrong address. The 
Boston Dispensary has* devised an immediate method of 
meeting such a situation for gonorrhea patients. The day the 
patient makes his first visit a letter is sent out to the address 
given. The clinic has taken a mail box so that if the patient 
is not at the address it is returned to the box and to the 
social worker without delay. In this way before the patient 
returns for the next visit the clinic has a check-up on his 
address. 

When a contagious case drops treatment before he is non- 
contagious, in communities with a reporting law he can be 
reported by name to the board of health, which urges treat- 
ment. The Boston Department of Health 2 reports much 
difficulty in following the cases whose treatment has lapsed 

. . . either because of the deliberate efforts on the part of such 
patients to conceal their identity or because of carelessness on the 

1 Lewis. Ora M., Medical Social Service as a Factor in Protective Work, 
National Conference of Social Work, New Orleans, April, 1920. 

2 Monthly Bulletin of the Boston Health Department, Boston, Oct., 1919, pp. 
127-128. 



THE FAMILY 153 

part of such patients or of the various agencies charged with the 
duty of making and transmitting records and reports with respect 
to them. The most important obstacles that serve to defeat the efforts 
of the local health department are: the fictitious names given by 
patients; fictitious addresses; fictitious names and addresses; the as- 
suming by the patient of the name or address, or both of some other 
person; changes in the addresses of patients, denials by persons 
visited of identity with the patients, and claims that the patients have 
merely assumed the names of the persons interviewed; claims that 
the patients are at the time of the inspector's call at work elsewhere 
than at the addresses reported ; and claims by patients that they have 
either never suffered from the diseases charged against them or that 
they have been cured. 

Some idea of the difficulties encountered in this work may be 
gathered from the fact that out of 196 cases under investigation by 
the department in October, 1919, only 44 cases were located. Eighty 
cases could not be found after diligent effort, and further search was 
abandoned. Three, it was definitely learned, had moved out of the 
city. At the close of the month 69 cases were still under investigation. 

A full-time investigator was then appointed to devote his 
entire time to the search for such patients. He was able to 
find many patients who had escaped discovery by the routine 
medical inspection. 

. . . Of 175 men referred to him ... 66 were found and 
proper action taken. All of these patients, but for the availability 
of the investigator for this special duty, would have escaped dis- 
covery, and in the absence of such information and advice as the in- 
vestigator was able to give them, and such pressure as he was able to 
bring upon them, would presumably have continued as lapsed cases, 
with grave likelihood of disaster to themselves, to their families, and 
to the public generally. 

Unfortunately in many localities the health department has 
no real power of enforcement. In St. Louis 1 however, the 
health department has the actual power to compel these cases 
to take treatment. Although by law only the clinic number 
is given to the board of health, the board of health and social 

l Weiss, R. S. and A. H. Conrad, The Medical and Social Care of Syphilis at 
the Washington University Dispensary, American Journal of Syphilis, voL 
iv, no. 2, April, 1920, p. 253. 



154 SYPHILIS OF THE INNOCENT 

worker cooperate so that all contagious cases sent to the 
municipal clinic are reported directly by name and address. 
If these patients do not appear, the board of health notifies 
the police department which brings them to the clinic. 

Many parents are not sufficiently interested to have their 
children treated and at times all efforts to persuade them fail. 
St. Louis 1 again meets this difficulty in a rather unusual 
manner. The court took the stand that parents must give 
satisfactory evidence that a luetic child was being treated 
somewhere. An officer of the juvenile court at the suggestion 
of the hospital worker visited the home saying that unless 
the child were treated the parents would be brought into 
court. The bare statement that the child was being treated 
elsewhere was not considered and the juvenile court took the 
responsibility of placing the burden of proof on the parents. 
The parents saw that treatment would be enforced and 
preferred to acquiesce than to have the nature of the child's 
disease brought before the court. It is interesting that this 
method was used in cases in which the Wassermann reaction 
was the only symptom, as well as in contagious cases. A case 
is given by the authors in which a young mother refused 
treatment for an apparently well twenty-seven months' old 
baby. It was made a court case and the judge forced the 
mother to continue treatment for the baby in spite of the fact 
that there were no apparent symptoms. 

Oftentimes treatment is refused on account of its cost. The 
situation still remains unsolved in many states. The question 
of payment for treatment was formerly acute in Massachusetts 
when salvarsan was expensive and the clinics had only a 
small supply for free distribution. At the present time the 
Massachusetts State Department of Health is manufacturing 
arsphenamin (salvarsan) for free distribution to authorized 
clinics. It is thus possible to treat a great many persons either 
without cost or at a very low rate. The decision on payment 
for treatment really should rest in the hands of the social 
worker. She should investigate the financial condition when 
necessary and should have the privilege of deciding who 
should pay nothing, who should pay on the instalment plan, 

l Jeans, and Butler, op. cit. 



THE FAMILY 155 

who should be aided by any of the outside agencies, and who 
should entirely pay for his own treatments. 

The treatment of the neurosyphilitic is a difficult question 
on account of the necessity for steady treatment over a period 
of years. It is practically true that once a patient, a patient 
almost for life. Moreover, many of these patients are below the 
normal in mental capacity and do not understand the situation 
thoroughly. They must constantly be persuaded of the value 
of treatment and the oftentimes impatient family must be 
inculcated with a sympathetic attitude towards the prolonged 
treatment. Cooperation with outside agencies which have well 
established relations with the patient often helps to keep him 
faithful to treatment. An examination of current treatment 
cases at the Psychopathic Hospital clinic showed that 40 per 
cent reported regularly without any special reminder other 
than general urging at the clinic. Thirty per cent needed 
letters and special clinic interviews. Thus 70 per cent re- 
ported regularly, leaving 30 per cent who reported irregularly 
in spite of letters and interviews. These recalcitrant active 
treatment cases as well as the cases whose treatment lapsed 
because they left town, moved, or refused more treatment 
were studied to see, first, what efforts were actually made by 
the social worker to avoid the irregularity or the loss to the 
clinic; and second, what might have been done. All patients 
were written to, telephoned, or visited. Often relatives were 
urged to cooperate and at times different visitors were tried 
on the same case. It was found that arguments often success- 
ful with other cases failed in these. The following points 
were made: 

1. The bad effects (physical and mental) of cessation of treatment. 

2. The good effects of continuous treatment (a start in life to a 
child, the possibility of a wife's bearing healthy children, the more 
rapid ending of the patient's treatment). 

3. The death of a relative from the same disease, as a warning. 

4. No job was worth giving up treatment. 

5. Lack of symptoms not indicative of health. Decision of when 
cured ought to remain with the doctor. 

6. The doctor's and social worker's time was wasted if the patient 
did not cooperate until the end of treatment. 

7. If treatment was discontinued, return to state hospital probable. 



156 SYPHILIS OF THE INNOCENT 

Suggestions as to what might have been done in any given 
case follow: 

1. More visits, fewer letters. 

2. Home interviews with patient, not messages through relative. 

3. Immediate follow-up when a new worker comes. 

4. More frequent telling the family of the nature of the disease (in 
the ease of children). 

5. Closer contact with the home, relatives, and employer (question 
of intensive investigation). 

6. More rapid follow-up of lapsing cases. 

7. Frequent demand for change of address. 

8. More frequent and earlier efforts to locate lost cases. 

9. Securing transportation for cripples and children. 

Difficulty of " Follow-up' ' of Private Patient. — Here again, 
as in the family follow-up, the follow-up of the private patient 
for treatment is a difficult problem. 

Case 114. Mr. Farrar Was a man of education and large financial 
success. He was rather a high type of individual. He was sent in 
consultation by his doctor for skin lesions and mucous patches. A 
history of syphilis in youth was obtained from him. The lesions were 
typical and the Wassermann reaction was positive. As usual in such 
cases, the disappearance of the lesions was almost miraculous under 
treatment. While under treatment, he stated that his daughter, a 
girl of 8, had recently had a mastoid operation, and that the bone was 
not healing well. This preyed upon his mind until finally he told 
the doctor who did the operation that he had had syphilis and won- 
dered if that had any relation to the difficulty with healing the bone 
lesion. The aurist was of the opinion that it might, and suggested 
that the little girl be examined. Mr. Farrar then began to worry 
that his wife would find out that there was something the matter with 
the girl, and finally decided that he would not have her examined 
for syphilis, but took her to another aurist. Finally the bone did 
heal, and nothing was done about the daughter. Shortly, thereafter, 
he also discontinued his treatment, although warned by his physician 
that he was not cured. His family physician, who was also a friend, 
tells the story that he knew him when he acquired his syphilis. At 
that time he took a very small amount of treatment from a quack, 
and refused to receive any other treatment. A couple of years later, 
he decided to get married. When his family doctor and friend heard 
of this he went to him and told him that he had no right to marry, 



THE FAMILY 157 

at least until a longer period had elapsed, and he had received more 
efficient treatment. The physician adds that the patient became quite 
indignant, and their relations became somewhat strained. The patient 
proceeded to get married. Everything- apparently went well, until 
the skin and mucous lesions appeared, and the patient went back to 
his old and true doctor friend who then sent him for proper treatment. 
Had this situation obtained with a clinic patient, the social service 
department would have put in a considerable amount of effort and 
probably would have succeeded in getting the child examined as well 
as the wife, and there is good reason to believe that the patient would 
not have been allowed to discontinue treatment when he was not cured. 
This case also shows: first, that it is the intelligent as well as the 
ignorant, who refuse to take the advice of conscientious and efficient 
physicians; and second, the mental torture that a man may suffer 
for years. 

To do such work and to do it satisfactorily and successfully, 
an efficient social worker is essential. A mere clinic clerk 
cannot accomplish all that is required. The social worker 
must have a good knowledge of case work technique, and an 
understanding of the problems of syphilis. Above all this, 
she must be level headed and must be able to handle people 
and situations with tact and judgment. Especially important 
is the correct mental attitude towards syphilis. No worker 
with a trace of the moralistic point of view can be successful in 
handling either the syphilitic or his family. An impersonal 
attitude towards the sensational features often present in 
syphilitic cases is essential. A third requisite is lack of fear 
of acquiring the disease. No person who is constitutionally 
timid or apprehensive should attempt to deal with contagious 
syphilis. 

Effects of Syphilis on Social and Mental Life — Atmosphere 
of the Home. — For a complete understanding of the part 
played by syphilis in the family one must not only consider 
its physical effect on patients and their families, and the 
importance of early diagnosis and continuous treatment, but 
one must also view the disease from the standpoint of the 
effect that it has upon the ideas, emotions, and the social life 
of the individuals concerned. The atmosphere of the family 
life may be markedly tainted through the ideas that are 



158 SYPHILIS OF THE INNOCENT 

engendered concerning the possible effects of syphilis. Late 
attacks of conscience are extremely frequent, and as a result 
of the brooding of the man or woman the whole surroundings 
may become poisoned. Probably there is no disease which 
is more likely to lead to phobias than is syphilis. Thoughts 
of infecting the spouse and of transmitting the disease to the 
children are likely to keep cropping up again and again. 
Each time a child is ill, the possibility that the disorder is 
due to syphilis may enter the parent's mind. Many persons 
become exceedingly morbid just because they know they have 
the disease. In those cases where the fear has not developed 
into a form of pathological phobia, a thorough examination 
of the family or the individual will often be quite sufficient to 
straighten out the patient's ideas, but when the phobia has 
become deep-set and harassing, the situation is much more 
difficult and will usually need a considerable amount of 
psychotherapy to alleviate it. 

Case 115. Alice Shelley came to the hospital after a hysterical at- 
tack. She was very much depressed and said, "The doctors say my 
blood is bad, I have a germ in me, it killed my baby boy, they say 
the poison is in my blood, they say I got it from my husband." The 
patient was a girl of 19 and had been married about a year. A few 
months before coming to the hospital she had been delivered of a still- 
born child. When she was six months pregnant she had developed a 
chancre, followed by a skin eruption, but she received no treatment. 
Her husband admitted having acquired syphilis one year previous to 
marriage. He had never been treated and claimed that no physician 
had told him that he could not marry. The patient had always been 
perfectly well until acquiring syphilis. There is every reason to 
suppose that if she had not become syphilitic she would have remained 
perfectly healthy and would have borne normal children. However, 
following the birth of a dead child and the psychic trauma which 
resulted from this and from the recognition of what was wrong with 
her, she changed from being a happy, easy-going person to one full of 
fears, doubts and worries. She felt that she was unable to work, and 
was afraid to leave the house for fear she would collapse. Upon ex- 
amination it was found that she had a mild involvement of the central 
nervous system. Her syphilitic symptoms rapidly cleared up under 
treatment but she continued to suffer with psychasthenic symptoms 
which stand a good chance of influencing the remainder of her life. 



THE FAMILY 159 

Different Reactions of Different Patients. — It is thus neces- 
sary to evaluate the individual equation of each patient. 
Some patients are more unfavorably influenced by insistence 
on the severity of the disease and the necessity of prolonged 
treatment than by the disease itself. Care must be exercised 
in dealing with sensitive individuals to prevent them from 
developing the feeling that the situation is entirely hopeless 
and that they will never be well again. 

Case 116. When seen in the clinic, Mrs. Flower was a pathetic 
picture. Tears were in her eyes every few seconds. Physically, she 
was quite an attractive woman of twenty-seven years of age, who gave 
the following story : Some seven years previously, she claims to have 
been raped. As a result, she developed both gonorrhea and syphilis. 
She immediately underwent treatment, but apparently developed a 
salpingitis necessitating operative intervention, since which she had 
never felt quite comfortable. She had received good antisyphilitic 
treatment from the time of her secondary symptoms. After a couple 
of years she married. She did not tell her husband of the condition 
until after marriage, when she found that it was impossible to keep 
her secret longer. As far as can be learned from the patient, this 
caused no marital difficulty. The husband was examined, and showed 
no evidence of syphilis. However, the patient continued to worry 
about herself, and after a year or two applied to the clinic for exami- 
nation as to her own condition. It was found that her Wassermann 
reaction was positive. She was put under treatment, and in a short 
time the Wassermann test was negative. However, she was kept un- 
der observation and just previous to the visit recorded above, the test 
had come back weakly positive. This entirely upset her. She was 
unable to sleep nights, her appetite was poor, she worried about her- 
self and cried a great deal. Her husband at the same time was 
launching out into new financial endeavors and having some difficul- 
ties. She felt that she ought to do some work to assist, but was in- 
capable of it on account of her various worries, pains, and aches. 
There was no question but that the patient had allowed herself to 
fall into a neurasthenic condition. As far as the disease itself was 
concerned, the chief sequel was sterility and this was probably the re- 
sult of gonorrhea rather than of syphilis. However, the other factor 
of importance was her poor mental condition. She stated that the 
greatest blow of all was when the latest test was reported as weakly 
positive. It would seem that more harm was done the patient in this 
case by retesting and following her so carefully than would have been 



160 SYPHILIS OF THE INNOCENT 

done had she been allowed to continue through life without as adequate 
medical attention. It is probable that with the amount of treatment 
already received, no further symptoms would have occurred, and 
she would have been a much more useful member of society. This 
is a very difficult condition to discuss. Every individual case has to be 
considered according to the mental attitude of the patient. Not only 
w T as her mental condition an affliction to the patient, but equally so 
to her husband who not only was deprived of the assistance that he 
might have received from a well wife, but furthermore, had a wife who 
was constantly worried, unhappy, and an unpleasant companion. 

Effect on Mental Life of Wife and Mother. — The mental life 
of the wife and mother is especially likely to become affected 
by syphilis either in herself or in any member of the family. 
If she herself is syphilitic she runs a chance of repeated acci- 
dents to pregnancies, which not only means an unnecessary 
and fruitless physical strain but may lead to mental depres- 
sion, and is very likely to produce the unhappiness of child- 
lessness. Her mental condition may be lowered by the keen 
realization of the meaning of the infection of husband or chil- 
dren even though she be free of worry about herself. She 
may imagine that one or all of the possible future horrors of 
syphilis are to descend on her family. The worry about a 
congenitally syphilitic child may be terrific, and there is noth- 
ing more pathetic than the vain hope for improvement of a 
defective congenital syphilitic. This constant w^ear and tear 
is hardly calculated to make a satisfactory home environment. 

Case 117. A diagnosis of congenital syphilis was made on Richard 
Shoemaker when he was a few weeks old and treatment was at once 
started. He was backward in development both physically and men- 
tally. Despite treatment he did poorly and at the age of 8 became 
unable to walk and began to deteriorate mentally. At 10 he presented 
a picture of juvenile paresis. For ten years the mother had been 
caring for the child whom she knew to be syphilitic. In early years 
she was hopeful of his mental and physical development and it was 
not until he was 8 years old that she really lost all hope. 

When there is not a complete understanding between the 
husband and wife or when the situation is not well handled, 
knowledge of syphilis may lead to estrangement. This is 
especially true in those cases w T here a great deal of suffering 
has been caused by a group of miscarriages or the birth of 



THE FAMILY 161 

frail congenitally syphilitic children. The trouble likely to 
result from a knowledge of syphilis can be very much min- 
imized when the matter is told in a careful and scientific man- 
ner. When the knowledge is accidental, difficulties are more 
prone to arise from the many prejudices that are commonly 
held by laymen to-day. 

Nursing Care as Disturbance to Family Life. — The actual 
physical care demanded by the members of a syphilitic family 
may cause a disturbance in the normal routine of family life. 
One syphilitic child may be such a burden that the other 
children suffer in care and attention. Constant visits for the 
treatment of a congenital syphilitic may mean that other 
children in the family are neglected. This becomes an impor- 
tant matter in poor families. The problem of the care of a 
congenital syphilitic is not limited to early childhood. It may 
extend from the days of adolescence to manhood. Interstitial 
keratitis, effusions of the knee, and other acute manifestations 
may necessitate a great deal of care. Feeble-mindedness, 
blindness, deafness, and the like may make children dependent 
for all time upon their parents and relatives. A paralyzed or 
bedridden man, a tabetic who not only cannot go about with- 
out assistance but who may suffer untold pain, an irritable or 
unreasonable paretic, add materially to the nervous tension 
in a family as well as increase the burden of care. 

Effect of Financial Difficulties on Home Life — Temporary 
Incapacitation. — The financial situation of the family may be 
seriously affected by syphilis. Temporary incapacitation of 
the wage earner in the early stages of syphilis leads to finan- 
cial loss in families of border-line economic status. Conta- 
gious patients rarely take time from work for hospital care, 
but ideally, hospitalization should be insisted on both for the 
rapid cure of the patient and his sterilization as a focus of 
infection. If it is carried out there is a chance that employ- 
ers might object and discharge the employee. Miss Lewis 1 

i Lewis, O. M., et al., A Clinic Studies Itself, Hospital Social Service, vol. iii, 
no. 1, Jan., 1921, p. 75. 



162 SYPHILIS OF THE INNOCENT 

cites the case of a girl who lost her job after hospitalization. 
The store doctor was willing to accept her as noncontagions, 
but the employment manager felt that anyone with a diagnosis 
of syphilis was socially a danger. The girl happened to have 
an extragenital, innocent infection. 

Industrial Decline. — The patient who has been temporarily 
absent from a job soon returns after treatment. Whether he 
is to have later financial loss depends on the adequacy of his 
treatment and his individual reaction to the disease. If the 
disease is uncured, it will probably appear again in later 
life in a more incapacitating form. Industrial decline is often 
a concomitant to a long-standing syphilis. 

Case 118. A striking example of industrial decline is that of Theo- 
dore Clarke. From a mining engineer who earned $300 per month 
and maintenance, he became a beggar who secured his subsistence 
from garbage cans. The entire cause of his decline in economic 
ability was a poorly treated syphilis the effects of which became mani- 
fest ten years after the disease was acquired. 

Case 119. George Powers had acquired syphilis five years pre- 
viously. His work record for these five years showed that he was a 
plumber by trade, earning a good wage, and considered an efficient 
workman by all his employers. Four years after his infection, how- 
ever, symptoms of nervous system syphilis appeared. The quality of 
his work markedly declined. Instead of high-grade mechanical work, 
he did odd laboring jobs and finally no work at all. 

Permanent Incapacitation. — Late manifestations of the dis- 
ease may entirely handicap the bread winner. Many a man 
who is incapacitated in the prime of his life by cardiovascular 
disease, by cirrhosis of the liver, by tabes, or by general 
paresis, becomes incapable of self-support and a serious drag 
upon his family. The expenses incidental to care may entirely 
ruin the family. The savings of many years may be used up 
and the family left destitute. Unless the family is well-to-do, 
someone — children, relatives, private or public charities — 
must aid in the care of the family. 

Case 120. Ernest Bloomfield was a tabetic of 42 who suffered severe 
pains. He was subject to gastric crises, attacks which made regular 



THE FAMILY 



163 



employment impossible, and reduced him to a state of irritability 
which made the family life extremely unpleasant. He was unable 
to ply his trade, that of a baker, and held odd jobs when he felt well 
enough. The family's support was the son-in-law's wage supple- 
mented by charitable aid. 

Case 121. James Pratt had always been a hard-working artisan, 
thoroughly competent and able to keep himself and family in fair 
circumstances in addition to putting aside a little money. When 
shortly past 50 he began to be bothered with shortness of breath to 
such an extent that he had to give up work. Examination showed 
that he had a very much enlarged heart with aortic insufficiency. 
This was of syphilitic etiology. Under antisyphilitie treatment and 
cardiac stimulants, the patient was kept quite comfortable but was 
unable to return to his work. At the end of some months he came to 
the clinic much distressed, saying that he had used up practically all 
of his savings, that he no longer had funds on which to live, and that 
he would have to go to work to support himself and his family. It 
was obvious, however, that his condition was such that he could not 
take up any arduous occupation and he was practically incapacitated 
as a money earner. The solution of the problem lay between depend- 
ing upon the work of the wife and charity of the relatives, or resi- 
dence in a public institution for the chronically ill. 

Financial Difficulties of Paretics. — Probably no one of the 
late manifestations of syphilis causes more varied financial 
difficulties than general paresis, which is the most frequent 
mental disorder due to syphilis and which is the late mani- 
festation of between 2 and 3 per cent of all patients infected 
with syphilis. The general paretic, particularly in the early 
stages of his disorder, is likely to commit many indiscretions 
of conduct. The grandiose paretic is apt to contract many 
debts which he is incapable of meeting or which may tax his 
competency, large or small, to the limit. His family or rela- 
tives may then have to struggle to make good his promises 
and may be left destitute. 

Case 122. Edward Smith was a traveling salesman in the late 
twenties. He was married and had just established a good home. He 
was making a fair salary and had managed to save a few hundred 
dollars. At this time mental symptoms of general paresis made their 
appearance and Mr. Smith became quite convinced that he was very 



164 SYPHILIS OF THE INNOCENT 

wealthy. He began to live as though his dreams were reality and in 
a couple of weeks he had not only spent all the money that he had 
accumulated in the course of years, but had acquired a number of 
debts which he was unable to meet, and by the time he was placed 
in a hospital his wife was left penniless. 

The actions of a paretic may be such as to lead to much 
embarrassment or even disgrace to the family. A hitherto 
respected member of the community may begin to drink and 
carouse and acquire anything but an honorable name. A man 
who has always been noted for his honesty may start pilfering 
and become entangled in the meshes of the law. 

Case 123. Laurence Gardina was arrested by the detective of the 
firm where he had worked for many years. He was accused of break- 
ing windows in the store and appropriating money. It seemed that 
when customers paid for their purchases he had the checks made out 
to him instead of to the company, and deposited a hundred dollar 
check to his own account. He also made mistakes in his work, sending 
orders to wrong addresses and selling food at too low a price. After 
his arrest he was sent to jail, where it was found that he had mental 
trouble. The hospital diagnosis was a typical case of general paresis. 

Poor judgment is one of the very early symptoms of general 
paresis. It may show itself in a great variety of ways. The 
personal and family life may disclose this factor or it may be 
particularly evident in business affairs, where lack of acumen 
brings disaster not only upon the sufferer but upon his family 
and business associates. 

Case 124. Thomas Walpole had never been a very prosperous man, 
but had supported his wife and been engaged in various moderately 
successful business deals. About 15 years previous to admission to 
the hospital he went into the real estate business which consisted 
largely of leasing and selling hotel property. He was particularly 
interested during the last few years in exploiting a beach hotel. He 
spent all his time in rebuilding the hotel and getting it ready to start 
business. The hotel had been open only a few weeks when it burned 
down. No insurance had been placed on the hotel and a fairly large 
amount of money was lost. After this, the patient was not able to 
reestablish himself in the real estate business. He was badly dis- 
couraged and worried about his property. 



THE FAMILY 165 

His wife at the time when the patient's business started to decline, 
supported the family by doing decorating for undertakers. When the 
patient entered the hospital with a diagnosis of syphilis, she was the 
main support of the household. After several months as an out- 
patient, Mr. Walpole was committed to a state hospital leaving his 
wife to support herself. 

Broken Home. — Closely bound up with the financial situ- 
ation is the problem of the broken home. Only too often the 
incapacity of the wage earner or his mate leads to a dissolu- 
tion of family life. The most unfortunate aspect is that this 
result of syphilis is no respecter of good homes or bad homes, 
happy marriages or unhappy marriages. 

The early death of a wife or husband may lead to the ruin 
of the home. Again paresis, one of the most virulent of the 
forms of late syphilis, is a frequent cause of early death. 
Its morbidity and mortality rate are almost equal. Dr. 
Salmon 1 has shown that one in nine of the 6909 men and one 
in thirty of the 5099 women who died between the ages of 40 
and 60 in New York in 1913 died from general paresis. These 
men and women in the best years of their lives drop out as pro- 
viders and also as active influences in the family for home or 
character building. 

An only too common occurrence is that the wife must carry 
the burden of supporting the home after the husband's death. 
Of interest here is the fact that life insurance companies 
to-day refuse to insure a known syphilitic on the ground that 
he is a poor risk and likely to die early. It is to be noted that 
the records of the Gotha Life Insurance Company, England, 2 
show that the mortality among syphilitics between the ages 
of 36 and 50 is well-nigh double the average rate, and other 
insurance records show the mortality at all ages to be at 
present about 30 per cent in excess of the average. Because 
of this, the families need even more protection. In many 
states, as in Massachusetts, there is public provision for aid 
to women who are widowed or whose husbands are public 

1 Salmon, T. W., General Paralysis as a Public Health Problem, Proceedings 
of the American Medico-Psychological Association, 70th Annual Meeting, Balti- 
more, Md., May 26-29, 1914, p. 180. 

2 Harmon, op. cit., p. 155. 



166 SYPHILIS OF THE INNOCENT 

charges, yet there are many cases in which a woman prefers 
to work and support her children in a home of her own choos- 
ing. Sometimes she boards them with relatives, other times 
she sends them to a school. The point is that because of her 
work she cannot keep them at home. 

A state hospital commitment, especially of a woman, often 
means the breaking up of a home. This again occurs in the 
prime of life, when both parents are especially needed. An 
examination of the ages of the first admissions of 755 paretics 
at the Psychopathic Hospital showed that the largest per- 
centage, 40 per cent of the total number, occurred between 
the ages of 31 and 40. 

Case 125. Giuseppe Frascati infected his wife. Six years after- 
wards she developed neurosyphilis which rendered her ineffective both 
as a housekeeper and homeinaker. She was committed to a state hos- 
pital with the result that her husband who was unable to supervise 
his child of 9 in the home, placed him out through the agency of a 
children 's society. 

Case 126. Luigi Sylvestri entered the out-patient department of the 
Massachusetts General Hospital when he was 41 years of age. He had 
been a concrete construction worker for a number of years but of 
late had been unable to do his work because of shortness of breath and 
pain in his chest. Examination disclosed the fact that he had a 
cardiac aneurysm and aortic insufficiency. His general condition re- 
sulting from these disorders was such that it was quite impossible for 
him to do any work whatever and it was not even good for him to be 
up and about. A very frequent cause of a condition such as the 
patient had is syphilis, and this proved to be so in his case. The pa- 
tient was married and had three children aged five, three, and two 
years respectively. Examination disclosed that all were infected with 
syphilis, and it became necessary for the entire family to undergo 
treatment. The patient, being a laborer and out of work, had no 
funds on which to keep the family. It became necessary therefore, to 
apply to Mothers' Aid for financial assistance but the amount allowed 
by the State for such purposes was insufficient to keep the family and 
offer bed care to the patient so that hospitalization became necessary 
for him. As such hospitalization meant a state institution and separa- 
tion from his family the patient objected. An attempt was made to 
supply extra funds from other charities in order to keep the family 
together and give the patient the care which was needed. This was 



THE FAMILY 167 

only a temporary makeshift, however, and the final solution had to be 
hospitalization for the patient, breaking up of the family unit, and 
charitable aid to the family. 

Statistical Studies of Social Difficulties in Patients with 
Syphilitic Mental Disease. — We recently reviewed 32 cases of 
syphilitic mental disease worked on intensively by the social 
service of the Psychopathic Hospital, with the aim of finding 
out which of these social difficulties were paramount in cases 
of syphilis of the nervous system requiring social care. Half 
of the married cases had some kind of family or marital diffi- 
culty varying from assault, threats, and jealous suspicions to 
definite estrangement, desertion, and non-support. Fifty per 
cent of these disorders affected the mate only and might be 
summed up under various degrees of marital discord. In the 
other 50 per cent the family unit was broken by desertion of 
wife, separation or estrangement from wife or children or 
both. 

The economic difficulties of the late syphilitic might well 
account for these discords in familial life. A decline in indus- 
trial capacity arising from a chronic inefficiency was manifest 
in some cases studied, others were temporarily incapacitated. 
On the one hand, these disorders led to inability to support a 
family; on the other, to employment difficulties. Thus, we 
found dependence on wife, relatives, and charity for support 
due to insufficient or lack of any income and a growing num- 
ber of debts. Considered statistically, we found that in the 
32 cases, 23 failed to adjust themselves to a competitive 
industrial world. 

Eecognizing the special frequency with which these eco- 
nomic difficulties arise in the families in which the bread- 
winner develops paresis, a more intensive study was made of 
the economic status of 41 married male paretics, the details 
of which are published elsewhere. 1 The conclusions, how- 
ever, may be considered here. It was found that in a normal 
self-supporting group of families, the entrance of paresis pro- 
duces the following effects: 

l Solomon, H. C. and M. H. A Study of the Economic Status of Forty-One 
Paretic Patients and Their Families, Mental Hygiene, vol. v, no. 3, July, 1921, 
pp. 556-565. 



168 SYPHILIS OF THE INNOCENT 

1. Over one half of the patients were receiving normal salaries at 
the time of admission to a state hospital. 

2. Two thirds, however, showed a decline in working capacity. 

3. The duration of this decline varied from one month to two years. 

4. In spite of this decline most of the patients were not discharged, 
especially by firms with whom they had worked for years. 

5. About one half were irregular at work or changed jobs frequently 
but only a few changed to less skilled labor. 

6. About one half gave a medical cause for finally leaving work 
while one half gave an industrial cause. 

7. Very few were out of work for a long time before admission. 

8. Although the wages were not markedly decreased nor the patient 
out of work for a long time before admission, the eating up of savings 
followed by the sudden cutting off of the income shows that almost 
one half of the wives went to work because of the patients' illness, 
three fourths of them working outside the home. 

9. Of 39 children whose mothers worked outside the home, 30 were 
under 14 and had to be cared for by other relatives. 

10. There was no increase in the number of children working, 
though some children already working had to assume heavier burdens 
than normally. 

11. Only a few families were forced to place out children. 

12. Two thirds of the families received permanent aid because of 
the commitment of the patient. This aid was from public and private 
agencies and relatives. 

13. At the time of the investigation, three fourths of the families 
had less income than when the patient left work. 

Syphilis and Marriage. — In view of the effect of syphilis on 
the physical, mental, and social life of the family, further 
consideration of a syphilitic 's right to marry is important. 
The question is one that has produced much difference of 
opinion. For those who believe that syphilis is always an 
incurable disease, and that the offspring of any individual 
who has had syphilis are likely to be tainted, it follows, of 
course, that a syphilitic can never marry. Although, there 
are a number of syphilologists who hold this point of view, 
we agree with the majority, who feel that under certain cir- 
cumstances a syphilitic may marry with safety to his mate 
and children. The point to decide is when a syphilitic is no 
longer contagious. 



THE FAMILY 169 

Opinions of Various Authorities as to Marriage of a Syphil- 
itic. — The discovery of the Wassermann reaction in 1906 and 
the introduction of arsphenamin treatment in 1909 have 
modified the ideas of many regarding the question of mar- 
riage, so that one must consider the opinions antedating and 
succeeding these diagnostic and therapeutic discoveries. Dr. 
Edward B. Vedder 1 has quoted Finger's conclusions, which 
were written in 1896 and which may be taken as representative 
of late nineteenth century German opinion: 

1. While untreated syphilis may lose its contagiousness and power 
of hereditary transmission, yet in numerous cases these powers may 
be retained for years, 

2. Systemic treatment shortens the contagious period so that at the 
end of four or five years the danger to the wife and children is small 
in the majority of cases. 

3. Experience shows, however, that in the most carefully treated 
cases a small fraction may retain the capability of transmitting the in- 
fection for 14 or 15 years, or even longer. 

4. It follows, therefore, that no definite rule can be deduced that 
will always be satisfactory. 

The minimal conditions for marriage as outlined by Finger 
are given as follows: 

1. A mild normal course of the disease. Severe visceral syphilis 
and malignant syphilis are excluded. 

2. An interval of at least five full years between infection and 
marriage. 

3. An interval of three years from the last syphilitic manifestation 
to marriage, with careful observation to determine the existence of 
slight erosions and other symptoms. 

4. A correspondingly systematic treatment of the disease. 

5. An energetic mercurial treatment just before the marriage. 

6. It is the duty of the physician to warn the patient that mar- 
riage may not be absolutely safe. That he must watch for small 
erosions on the genitalia or in the mouth that may infect his wife. 
The family physician should know the facts so that he can watch both 
the wife and children, and afford prompt treatment should it become 
necessary. 

i Vedder, op. eit., p. 206. 



170 SYPHILIS OF THE INNOCENT 

French opinion of this period is best represented by Four- 
nier, 1 who formulated the rules which have influenced the 
entire world: 

1. Absence of actual specific lesions. 

2. Advanced age of the infection. 

3. Certain period of absolute immunity following the last specific 
manifestations. 

4. Non-menacing character of the disease. 

5. Sufficient specific treatment. 

Pusey 2 gives the following views as among the representa- 
tive opinions at the beginning of the twentieth century: 

Taylor: If the treatment is thorough, marriage is safe for a 
syphilitic man two and a half years after infection. 

Keyes: If during the last two years there has been no treat- 
ment and no symptoms, marriage is safe after five years. 

Morrow: If the treatment has been sufficient, if the patient 
has been without symptoms for 18 months, and if four years 
have elapsed since the infection, marriage is safe. 

Pusey quotes Gennerich and Hoffman as representative of 
present-day conservative opinions. Gennerich believes mar- 
riage may be permitted after two years of vigorous treatment 
if the Wassermann reaction is negative and there have been 
no relapses. Hoffman believes in the old rule that if a patient 
has had good treatment and has been symptom-free for two 
years he may safely marry three to five years after infection. 

Dr. Vedder 3 gives a modified form of Finger's views as his 
opinion: 

1. A mild course of the disease. 

2. An efficient course of treatment with both salvarsan and 
mercury in accordance with the best practice in the treatment 
of syphilis. 

3. An interval of at least four full years between infection 
and marriage. 

1 Fournier, op. cit., p. 91. 

2 Pusey, W. A. Syphilis as a Modern Problem, Chicago, American Medical 
Association, 1915, p. 99. 

3 Vedder, op. cit., p. 209. 



THE FAMILY 171 

4. An interval of three years from the last syphilitic mani- 
festation to marriage, with careful observation to determine the 
existence of symptoms. 

5. A negative Wassermann reaction just before marriage, best 
confirmed by a test at a second laboratory to ensure accuracy. 

Browning and Watson 1 feel that marriage should not take 
place until after two years of vigorous treatment, and then 
only if there are no lesions six months after the end of treat- 
ment. If the Wassermann reaction is positive after the two 
years, more treatment must be given. Marriage can then 
take place even if the Wassermann reaction is still positive, 
but both husband and wife should be treated. 

Typical of modern French opinion is the report of a 1920 
commission appointed to study the question of the marriage 
of syphilitics. 2 The conclusion was that if the patient were 
seen and treated before the reaction became positive or 
before he manifested any secondary reactions and he remained 
free from positive serology and secondary manifestations dur- 
ing the first year, it was safe for him to marry at the end of 
two years. On the other hand, if he were seen after the sero- 
logical reaction became positive or he showed secondary symp- 
toms, intensive treatment was necessary for two years, but 
if at the end of that time all the tests were negative it would 
be safe for him to marry, two years having passed since his 
infection. If, in the latter case, the serological reaction 
remained positive it was considered safe for the patient to 
marry if he were a man and if his spinal fluid were normal. On 
the other hand, if in spite of treatment the spinal fluid were 
positive, the physician was urged to exercise great care in ad- 
vising marriage. Marriage was considered safe if, after treat- 
ment, the spinal fluid became negative and remained so for 
several years. Obvious signs of nervous system syphilis were 
considered a definite bar to marriage and physicians were 

i Browning, C. H. and D. Watson. Venereal Diseases; a Practical Handbook 
for Students. With an introduction by Sir John Bland-Sutton. New York, 
Oxford University Press, 1919, p. 120. 

2 Report of a Commission for the Study of the Question of the Marriage of 
Syphilitics. Bulletin Societe francaise de dermatologie et de syphilologie, 1920, 
p. 233, translated in Venereal Diseases, by Ormsby and Mitchell, Practical 
Medicine Series, Chicago, vol. vii, 1920, p. 169. 



172 SYPHILIS OF THE INNOCENT 

warned to be careful about advising marriage if the patient 
was an old syphilitic who could not give a good account of 
the date of infection or the amount of treatment. 

Stokes 1 believes that contagious patients should be gov- 
erned by the Hoffman five-year rule, which is almost "identi- 
cal with the standard of cure in the fully developed case of 
secondary syphilis/ ' He does not feel that conservative 
syphilologists should shorten the period because of modern 
treatment by salvarsan. 

Pusey 2 points out that the time when it is safe for a man 
to marry without danger of infecting his wife, and hence his 
children, depends on the duration and frequency of the 
relapses in secondary syphilis. He considers tertiary syphilis 
practically noncontagious. In cases which are poorly treated 
or not treated at all relapses are more frequent. He quotes 
Sperk, who in 1518 cases of secondary syphilis among prosti- 
tutes found relapses in all but 10. Lewin, in 6000 cases treated 
with sublimate injections, found 40 to 45 per cent relapses; 
Linden, in cases treated with calomel injections, had relapses 
in 30 per cent of his cases. Gennerich, in treating army men 
with mercury and salvarsan, reduced the number of relapses 
to 5 per cent. Thus, the matter of relapses seems to depend 
on adequate, early treatment. Pusey thinks that contagious 
lesions are rarely found after three years, and almost never 
after five. Fournier 3 observed 643 late secondaries in 19,000 
cases. 

Statistics 4 have been compiled showing the duration of the 
secondary period. In 1000 cases from Tarnowski's clinic 
observed for ten years, the last lesions developed within the 
first five years in 802 persons; within the second five years 
in 167 persons ; within the third five years in 26 persons ; and 
within the fourth five years in 5 persons. Thus the older the 
infection, the less frequent are secondary lesions. 

1 Stokes, J. H. To-day's World Problem in Disease Prevention, Washington, 
D. C, United States Public Health Service, Treasury Department, p. 98. 

2 Pusey, op. cit., p. 95. 

3 Fournier, A. La Syphilis des Honnetes Femmes, extrait du Bulletin de 
l'Academie de rnedecine, Seances du 2 et du 9 Oct. 1906. 

4 Tschistjakow, Die Condylomatose Periode der Syphilis, Inaugural Disserta- 
tion, St. Petersburg, 1894, quoted by Vedder, p. 113. 



THE FAMILY 173 

The final word from America to date is given in the con- 
clusions of the All-America Conference on Venereal Diseases, 
December, 1920 1 1 

Resolved, That with reference to the eligibility for marriage of 
the individual who has or has had syphilis the following medical 
considerations apply: 

1. The eligibility for marriage of the person who has or has 
had syphilis depends in the main upon the possibility of his 
transmitting the disease. 

2. The impossibility of absolutely determining by arbitrary 
rule the limits of infectivity in all cases has been admitted. 

3. The problem may be more difficult of solution in women 
than in men, owing to the paucity of clinical and laboratory evi- 
dence of the disease in the former. 

4. The clinical experience of many years has justified, as rea- 
sonably safe, the following fundamental requirements: 

(a) Three years of effective treatment. 

(b) Two additional years of freedom from all signs and symp- 
toms of the disease, under medical observation. 

5. It is recognized that special types of cases may call for 
special interpretation, which, however, in all cases should be 
founded on the basic principles of effective treatment and pro- 
longed painstaking observation for signs of recurrent or active 
syphilis. 

6. In view of the inevitable element of uncertainty, however 
small, the prospective marital partner of a person who has or 
has had syphilis should be informed before marriage of the 
status of the case. 

7. Medical examination to establish the presence or absence of 
syphilis before marriage should include not merely a blood Was- 
sermann test but an examination, clinical and serologic, of the 
entire body. If evidence of a previous or probable syphilitic in- 
fection presents, such examination should be especially searching, 
may include a period of observation, and should be interpreted 
by an expert. 

It is evident that all these opinions allow a great latitude 
in the interpretation of the term "noncontagious." It is also 
clear that the time element is brought in as a more important 

i Resolutions of All- America Conference on Venereal Diseases, Public Health 
Eeports, vol. 36, no. 28, July 15, 1921, p. 1063. 



174 SYPHILIS OF THE INNOCENT 

factor than a negative Wassermann reaction. There are many 
cases which, despite the most intensive treatment, continue to 
have positive Wassermann reactions in the blood. Despite this 
fact, many of these patients may be considered as probably 
noncontagious, and from that standpoint, fair risks for mar- 
riage. Unfortunately, many lawmakers feel that a negative 
Wassermann reaction is the most important point in an exam- 
ination for syphilis. Besides the difference which personal 
interpretation and technique make in evaluating any Wasser- 
mann reaction, there is the danger that satisfaction with a 
negative Wassermann reaction will mean that some early 
cases of syphilis as well as some cases of neurosyphilis will 
escape the doctor's notice. 

Case 127. What may result from relying on a negative Wasser- 
mann reaction is shown by the case of Max Goldstein. As the hus- 
band of a general paretic he was examined and found to have an early 
neurosyphilis for which he underwent treatment. He was anxious 
to remarry shortly after the death of his wife. He was urged against 
this by the hospital physicians on the ground that he was a poor risk 
for marriage. He had had a great many positive Wassermann reac- 
tions as well as some negative Wassermanns. In view of his desire 
to marry he went to a physician who sent a sample of his blood to a 
laboratory for a Wassermann test which was reported negative. On 
this ground he felt justified in marrying and refused to return to the 
clinic for treatment. The Wassermann test on the blood was of ab- 
solutely no value in this case as the patient was a neurosyphilitic. Al- 
though there was no danger of familial infection the patient was a 
poor economic risk. 

Legislation Regarding Syphilis and Marriage. — In recent 
years there has been considerable advance in legislation in 
the United States regarding syphilis and marriage, due, no 
doubt, to the increased publicity given to the question. These 
laws are interesting: first, from the point of view of syphilis 
as a bar to marriage, and second, as the means of making the 
marriages void. The following 17 states have provisions 
relating to venereal disease as a bar to marriage i 1 

l Office of the Surgeon General, Division of Venereal Diseases. 





THE FAMILY 




Alabama 


North Carolina 


Vermont 


Indiana 


North Dakota 


Virginia 


Maine 


Oklahoma 


Washington 


Michigan 


Oregon 


Wisconsin 


New Jersey 


Pennsylvania 


Wyoming 


New York 


Utah 





175 



The general aim of the laws is to prevent the marriage of 
infected persons. How this purpose is carried out can best 
be shown by an examination of some of the laws. Some states 
merely prohibit the marriage of persons who know they have 
a venereal disease. For instance, Michigan forbids the mar- 
riage of a person with a venereal disease, but does not offer 
any provisions for enforcement or penalties for disregarding 
the law. 

In other states nothing further is demanded than a state- 
ment from both applicants under oath that they are free from 
a venereal disease or that they have no transmissible, un- 
cured, or contagious disease. For example: 

The New York law makes it the duty of the town or city clerk, 
before issuing a marriage license, to secure a statement from each of 
the parties to the marriage in the following words : "I have not to 
my knowledge been infected with any venereal disease, or if I have 
been so infected within five years I have had a laboratory test within 
that period which shows that I am now free from infection from any 
such disease." 1 

In Pennsylvania one need only state that one is free from 
any i i communicable ' ' disease, while in Washington this is 
only required for the male applicant. 2 

Alabama, North Dakota, Wisconsin, and Oregon provide 
for a medical certificate. Alabama's law of 1919 reads: 

No license may be issued to a person who fails to present to the 
issuer a certificate by a licensed physician setting forth freedom from 
venereal diseases so nearly as can be determined by a thorough exam- 
ination and by the application of the recognized clinical and labora- 
tory tests of scientific research, when in the discretion of the examin- 

i Venereal Disease Legislation, Public Health Reports, Jan. 18, 1918. 
2 Social Hygiene Legislation Manual, 1921, Publication 312, American Social 
Hygiene Association. 



176 SYPHILIS OF THE INNOCENT 

ing physician such clinical and laboratory tests are necessary. All 
males within 15 days prior to application for a license shall be exam- 
ined. No marriage shall be entered into in any manner whatsoever 
without the male party shall have first submitted to the ante-nuptial 
examination referred to . . . and having with him a certificate 
from such physician of his freedom from such diseases. 1 

Wisconsin's statute of 1917 reads: 

. . . within 15 days prior to the application all male applicants 
must be examined for venereal disease by a physician licensed to 
practice in Wisconsin or in the state in which the applicant resides, 
and must file with the clerk the physician's certificate showing that 
the applicant is free from such disease. Any person who has been 
afflicted with gonorrhea or syphilis must file a certificate from the 
designated state laboratory showing that such person has been 
examined and is not in a communicable stage of the disease. 

Although a licensed physician must state that every appli- 
cant is free from venereal disease, there is, unfortunately, no 
mechanism provided to avoid the certificate of the ignorant 
doctor who is satisfied with a negative Wassermann reaction 
as evidence of freedom from syphilis. Nor when there is a 
suspicion of syphilis is there any means of securing a thor- 
ough medical examination consisting of a history of the pa- 
tient and family, thorough physical examination, repeated 
blood tests, and examination of the spinal fluid. 

Indiana, Maine, Michigan, New Jersey, Vermont, and 
Oklahoma go further. It is a misdemeanor (in the case of 
Oklahoma, a felony) for persons with a venereal disease to 
marry, while in Maine it is a misdemeanor for persons with 
syphilis to marry. The New Jersey law, March 14, 1917, 
reads : 

1. Any person, who knowing himself or herself to be infected with 
a venereal disease, such as chancroid, gonorrhea, syphilis, or any of 
the varieties or stages of such diseases has sexual intercourse, shall be 
guilty of a misdemeanor. 

l Hall, F. S. and E. W. Brooke, American Marriage Laws in Their Social 
Aspects, New York, Russell Sage Foundation, 1919. 



THE FAMILY 177 

An interesting point here is that "any variety or stage' ' 
is considered in the law, irrespective of whether it is con- 
tagious or not. This is an example of how an otherwise good 
law can go too far by being too inclusive. The law might be 
used to include noncontagious, symptom-free, latent syphilis 
which "varieties" are not dangerous through intercourse. 

Provision is often made for penalties if the marriage is 
consummated in spite of the existence of the contagion. 
Thus Oklahoma, in senate bill No. 43, Section 3, demands: 

. . . any person who shall, after becoming an infected person 
and before being discharged and pronounced cured by a reputable 
physician in writing, marry any other person, or expose any other 
person by the act of copulation or sexual intercourse to such venereal 
disease or to liability to contract the same, shall be guilty of a felony 
and upon conviction shall be punished by confinement in the 
penitentiary for not less than one year or not more than five years. 

Michigan, Vermont, and Maine laws apply this to syphilis 
specifically. Michigan's penalty in 1915 reads: 

Marriage by a person with syphilis or gonorrhea is deemed a felony 
and is punishable by a fine of from $500 to $1000, or imprisonment 
for not more than five years, or both, and it is provided that in such 
prosecution, the husband or wife may be examined as witness against 
each other, whether they consent or not, and that any physician who 
attended the defendant shall be compelled to testify. 1 

Vermont, 1915, provides: 

A person who, having been told by a physician that he or she was 
infected with gonorrhea or syphilis, marries, without assurance and 
certification from a legally qualified practitioner of medicine and 
surgery that he or she is free from gonorrhea or syphilis, shall be fined 
not more than $500 or imprisoned not more than two years. 1 

Maine passed in 1919 an act relating to the marriage of per- 
sons having syphilis: 

Sec. 1. No person having syphilis shall marry until he has a 
certificate from the attending physician or physicians that he is cured 

l Hall and Brooke, loc. cit. 



178 SYPHILIS OF THE INNOCENT 

of syphilis. The state board of health is hereby empowered to make 
regulations prescribing the methods to be employed in diagnosticating 
said disease. 

Sec. 2. Every physician shall keep a record of all cases of syphilis 
that come under his observation and care, and shall use reasonable 
means to ascertain the intentions of syphilitic patients as to marriage. 
The physician shall -warn said patient of the legal, moral, and physical 
evils of marriage contracted by them. If the physician learns that 
a patient as aforesaid has filed intentions of marriage as required by 
law, or if the physician believes that the patient as aforesaid intends 
to marry, the physician shall notify the local board of health or the 
health officer in the town or city in which the patient resides, who are 
hereby empowered to notify the other party to the intended marriage. 

Sec. 3. Any person failing to comply with the provisions of sec- 
tions one and two and any physician making a certificate as aforesaid 
falsely shall be punished by imprisonment for not less than three 
months nor more than one year or by a fine of not more than five 
hundred dollars or less than two hundred dollars, or both. Municipal 
and police courts and trial justices shall have jurisdiction of the above 
concurrently with superior and supreme judicial courts. . . . 

The following states make the marriage of persons with 
venereal disease void: 1 

Connecticut Maine Rhode Island 

District of Columbia Massachusetts South Carolina 

Georgia Michigan Utah 

Illinois Minnesota West Virginia 

Kentucky Nebraska 



o J 



Other states have recently passed statutes making venereal 
disease a ground for annulment as for instance, Indiana, 
North Dakota, Pennsylvania, and Washington. 

States which do not have specific laws have recently an- 
nulled marriages, granted separations or specific damages, on 
other grounds. 

The marriage of a syphilitic has been annulled recently in 
the United States on the basis of fraud. In a recent Kansas 
case, the wife discovered the day after marriage that her hus- 
band was syphilitic. She was unable to obtain a divorce for 
a year but the marriage was annulled on the ground that the 

l Social Hygiene Legislation Manual, loc. cit. 



THE FAMILY 179 

husband was not physically fit to enter into marriage rela- 
tions and that the marriage was fraudulent. 1 

The case is also cited where a separation was granted on 
the ground of cruel treatment. In this case the wife acquired 
gonorrhea and syphilis from her husband. (Louisiana, 
1912.) 

In a New Jersey case, 1914, the admission of a defendant 
in a divorce proceeding to members of his family that he had 
given his wife the disease if sustained by corroborating cir- 
cumstances was sufficient ground for granting the decree. 

The Supreme Court of North Carolina, 2 recently affirmed . . . 
a judgment in favor of a wife who asked for actual and punitive dam- 
ages because . . . her husband contracted a venereal disease and 
"took advantage of his marital relation with said plaintiff and in- 
fected her with said vile and loathsome disease." . . . The jury 
assessed the plaintiff's damages at $10,000. ... It was held that 
no principle of justice can maintain . . . that a debauchee can 
marry a virtuous girl . . . keep up his intercourse with lewd 
women, contract . . . venereal disease, communicate it to his 
wife . . . and ruin her physically for life . . . yet be ex- 
empted from all liability by the assertion that he and his wife are 
one, and that he being that one, he owes no duty to her of making 
reparation to her for the gross wrong that he has done her. 

The value of these laws might be questioned as they do not 
entirely cover the ground in content or means of carrying 
them out. Their fallacies have been pointed out by a recent 
survey of some "eugenic" marriage laws. 3 Here the Wiscon- 
sin law is taken as an example of the most effective modern 
legislative effort. The writer believes that although the 
direct effect of the law has been wholesome its value is mostly 
moral and educational. The weaknesses in the practice of 
the law are given as follows: 

1 Mimeogram, Aug., 192-0, U. S. Interdepartmental Social Hygiene Board, 
pp. 7-9. 

2 Journal of the American Medical Association, vol. 76, no. 4, Jan. 22, 1921, 
p. 265. 

3 Roloff, B. C, The "Eugenie" Marriage Laws of Wisconsin, Michigan, and 
Indiana, Social Hygiene, vol. vi, no. 2, April, 1920, pp. 230-238. 



180 SYPHILIS OF THE INNOCENT 

1. The tendency, which thus far has not been successfully 
checked, of couples who desire to evade the provisions of the 
Wisconsin law, to be married in neighboring states. These states 
either have no "evasion" act to prevent this practice (e. g., 
Michigan) or their officials, reaping a harvest of fees by reason 
of the exodus, wink at the evasion (e. g., Illinois). 

2. The failure to include in the ' ' eugenic ' ' section the require- 
ment that a medical certificate shall be furnished by the female 
as well as the male. 

3. The likelihood that the present simple requirement of an 
examination by a licensed physician is in no wise a guarantee 
that the applicant is free from venereal disease, a fact admitted 
by leading physicians within and without the state. 

4. The ease with which (owing to the 15 days' grace between 
the application for a license and the 30 days' grace between the 
issuance of the license and the solemnization of the marriage) 
the purpose of the act may be avoided by the young man who 
goes out for "one last celebration" before the wedding, and 
acquires syphilis or gonorrhea subsequent to the medical 
examination. 

The following suggestions have been made as a method of 
improving these laws: 

1. The adoption and enforcement by all states concerned of 
the standard "Marriage Evasion Act" recommended by the Con- 
ference of Commissioners on Uniform State Laws. Illinois and 
Wisconsin already have substantially this act. But . . . 
there is a difference of opinion among legal authorities in Wis- 
consin, and definite decision and interpretation are needed to 
validate the law. Michigan needs such a law. And a strict 
holding to account of the officials of these states by the local 
district or prosecuting attorneys is essential. 

2. A "eugenic" certificate should be required of the female as 
well as the male. The difficulty of developing the details of such 
a provision is admitted, as well as the need to guard against its 
abuse. That such examination for women should be performed 
by women physicians is believed by many to be essential to the 
success of such an act. 

3. The difficulties in the way of obtaining a reliable cure for 
women afflicted with gonorrhea are well known to medical men. 
Although the refinement of laboratory tests for syphilis and 
gonorrhea is by no means complete, yet in the hands of experts 



THE FAMILY 181 

they are the best available means of diagnosis, and without them 
the whole issue remains vague and uncertain.. Laboratory tests 
were originally part of the Wisconsin law, but the requirement 
was repealed because of the apparent hardship to applicants. I 
cannot help but voice the opinion that laboratory tests should be 
restored as part of the examination. 

4. The obvious remedy for the situation outlined in paragraph 
4 under defects would be to require the examination to take 
place within a shorter time previous to the solemnization of the 
marriage — say five days. This would not solve the problem 
entirely, but would at least serve to reduce the number of 
premarital infections. 

In spite of the inadequacy of even the best laws it would 
seem that the efforts of all individual states must be of value. 
Just as prohibition and woman suffrage became national 
amendments, due partially to the local interest in wet and 
dry states and in suffrage and anti-suffrage states, so it is pos- 
sible that these unrelated so-called "eugenic'' marriage laws 
may lead to uniform national laws. 

Importance of Physician's Influence Regarding Marrying 
of Syphilitics. — In considering the law as a means of pre- 
venting family infection one cannot ignore the important per- 
sonal influence of the physician upon the whole situation. A 
man or woman who has had syphilis deserves a thorough 
examination by a competent physician before marriage. It 
is the duty of the family physician to make such an examina- 
tion himself or if there is any question of the diagnosis to 
send the patient to a syphilologist for final decision. 

It is not only essential for the physician to establish the 
degree of safety with which a patient can marry but if the 
patient insists on marriage and there is any danger the physi- 
cian should inform the other party. Here again the oath of 
Hippocrates is often invoked. It seems clear to us, however, 
that the physician has a greater duty to the community — 
represented by the future mate and children — than he has to 
the individual. A warning of future possibilities is the due 
of every person who is to marry a syphilitic as well as of 
every syphilitic who intends to marry a non- syphilitic per- 



182 SYPHILIS OF THE INNOCENT 

son. Not only generalities but definite points must be brought 
out, such as: the danger of moist and open lesions; the pos- 
sible infection of the fetus by the wife even though she is 
without obvious lesions; the fact that symptom-free does not 
mean disease-free; the necessity of long and regular treat- 
ment, and the chances of involvement of the visceral, vascular, 
and nervous systems and of resulting incapacity. 

Case 128. The social complication appeared in this case when we 
received a letter from Mark Cochrane 's fiancee, asking us what was 
the matter with him and whether she could marry him. She said 
that he told her he had a "nervous breakdown." The patient, a 
young man of 28, had had a chancre six years previous. Although 
he had been treated and had been under care for a year, he had devel- 
oped an early paresis with considerable mental deterioration. He 
could marry without danger of infecting his wife, but he could in 
no way make an adequate husband. He had not been earning a 
living for over a year, and could not support a family. He needed 
oversight on account of his spells of unconsciousness and would 
undoubtedly deteriorate more and more during the next few years. 
We felt entirely justified, after urging the patient to tell his fiancee 
the truth, in going over the situation thoroughly with her, so that she 
might have all the facts on which to base a judgment. 

Legal Attitude Towards Physicians and Medical Secrecy. — 

An indication that the legal attitude towards physicians is 
changing, is given in the above marriage laws which demand 
a health certificate. The implication of such laws is that the 
doctor, by refusing to sign a certificate, discloses syphilis and 
stops the marriage. However, most of the existing laws as 
to libel and professional confidence do not give much free- 
dom to the physician. Wigmore 1 says "protection is not ex- 
tended to medical persons in regard to information which 
they have acquired confidentially by attending in their pro- 
fessional character.' ' Wigmore, however, does not believe 
that medical testimony should be a privileged communication 
as it is too important and decisive. More and more in recent 
years jurisdictions have revoked this privilege. For example, 

l Wigmore, J. H., Treatise on the Law of Evidence, by Simon Greenleaf, 
revised by J. H. Wigmore, Boston, Wile and Brown, 1899. 



THE FAMILY 183 

Ohio 1 in 1915 made a certain provision for physicians to ex- 
pose facts to interested persons. 

Section 1275. The State Medical Board may refuse to grant a cer- 
tificate to a person guilty of . . . grossly unprofessional or dis- 
honest conduct. . . . The words "grossly unprofessional or 
dishonest conduct ' ' as used in this section are hereby declared to mean : 

Second, The willful betrayal of a professional secret. But a physi- 
cian, knowing that one of the parties to a contemplated marriage has 
a venereal disease, and so informing the other party to such contem- 
plated marriage, or the parent, brother, or guardian of such other 
party, shall not be held to answer for betrayal of a professional secret, 
nor shall such physician be liable in damages for truthfully giving 
such information to such other party, or the parent, brother, or 
guardian of such other party. 

Other state laws support this position even more positively : 

The Maine act requires physicians, under penalty, to notify the 
local health officer if an infected patient intends to marry, and the 
health officer is empowered to notify the other party. In the public 
interest the physician is not only permitted to disregard what had 
hitherto been considered a professional secret, but it is made his duty 
to do so. 2 

The English situation has been summed up by the Koyal 
Commission on Venereal Diseases: 3 

The difficulty of communicating with or warning the future bride, 
or her parents or other persons in a position to influence her action, 
is twofold. We are informed by many witnesses that it might be 
regarded as a breach of professional confidence. There is also the 
possibility of the medical practitioner being sued or prosecuted. 
There is no doubt that to assert to a third person that any one is 
suffering from a venereal disease is, if in writing, a libel, or if by word 
of mouth, a slander. The witnesses who have dealt with the difficulty 
thus created have somewhat magnified its extent ; for in a civil action 
against a medical practitioner, proof of the truth of the defamatory 

i Worthington, G. E., Developments in Social Hygiene Legislation, from 
1917 to September 1, 1920, American Social Hygiene Association, Publication 
Ko. 313, p. 569. 

2 Venereal Disease Legislation, Public Health 'Reports, loc. cit. 

3 Royal Commission on Venereal Diseases, op. cit., pp. 56-7. 



184 SYPHILIS OF THE INNOCENT 

words affords a complete defence; and in criminal proceedings, if 
the jury should find that the defamatory words were true in substance 
and in fact, and also that it was for the public benefit that the matters 
charged should be published, the defendant would be entitled under 
Lord Campbell's Act to judgment in his favour. In a case, therefore, 
where there can be no reasonable doubt as to the accuracy of the 
diagnosis, a medical practitioner would be in a secure position so far 
as the result of the trial is concerned, though it must be admitted that 
the award of costs to him would usually be a very inadequate com- 
pensation for the loss of time and for the trouble caused even by a 
successful defence. But in some cases, e. g\, where he has simply 
expressed his opinion that the intending husband is "not cured' 7 or 
1 ' is not yet in a condition to make it safe for him to marry, ' ' it might 
be dangerous for him to take on himself the burden of justifying, 
since a doubtful or speculative issue would then be raised. 

This point of medical secrecy arose in London recently 1 
when a physician was called in a divorce case to give evidence 
that he had treated the wife for syphilis. Adultery had been 
proved but cruelty had also to be proved by the woman. The 
physician brought a letter from his hospital saying that 
absolute secrecy was enjoined on the physician. The judge 
ruled that evidence should be given on the ground of justice. 
This is an advanced and not entirely universal point of view. 
Many English physicians objected to "giving away" their 
patients and felt that such a policy would lower the attend- 
ance at venereal clinics. 

In this chapter an attempt has been made to show how 
syphilis affects the family unit. Syphilis acquired by the 
unmarried tends to lower the marriage rate, as many a syph- 
ilitic feels he has no right to marry. If syphilis does not pre- 
clude the right to marriage, it should postpone the date con- 
siderably. When a syphilitic marries or a married person 
acquires syphilis the whole family becomes implicated. The 
possibilities of marital infection, sterility, accidents to preg- 
nancies, stillbirths, and congenitally syphilized children are 
to be considered. The whole structure of family life may be 
changed. Illness of the individual members of the family 

i Journal of the American Medical Association, vol. 74, no. 9, Foreign Cor- 
respondence, Feb. 28, 1920, p. 614. 



THE FAMILY 185 

affects the other members. Disabilities, frequent in middle life 
at a time when efficient parents are most necessary, lead to 
much hardship for the entire family. The frequency of the 
disease as a family problem is so great that it may be thought 
of as the general rule. This would lead to the practical plan 
of considering the family of every syphilitic and make for 
a thoroughgoing medical and social investigation. 

REFERENCES 

Bartlett, F. H., Effect of Venereal Disease on Infant Mortality. American 

Journal of Syphilis, vol. ii, no. 1, Jan., 1918. 
Blaisdell. J. H., The Menace of Syphilis to the Clean Living Public, Boston 

Medical and Surgical Journal, vol. clxxii, no. 4, April 1. 1915. 
, The Menace of Syphilis of To-day to the Family of To-morrow, Boston 

Medical and Surgical Journal, vol. clxxv, no. 1. July 6, 1916. 
Browning. C. H., and D. Watson, Venereal, Diseases: A Practical Handbook for 

Students, with an introduction by Sir John Bland-Sutton, New York, 

Oxford University, 1919. 
Dempset, Infant Mortality, Results of a Field Study in Brockton, Mass. Children's 

Bureau, U. S. Department of Labor, Series No. S, Bureau Publication No. 37. 
Department of Medical Social Work, Boston City Hospital, Feb. 1, 191 8- Jan. 

31, 1919. 
Dublin, L., Birth Control, Social Hygiene, vol. vi, no. 1, Jan., 1920. 
Fournier, A., La Syphilis des Honnetes Femmes, extrait du Bulletin de 

1'Academie de Medecine, Seances du 2 et 9 Oct., 190(3. 

. Syphilis et Marwge, Paris, G. Masson, 1880. 

Gow, W. J., Syphilis in Obstetrics {System of Syphilis, vol. ii), second edition, 

London, Frowde, Hodder, and Stoughton, 1914. 
Habermann, J. V., Hereditary Syphilis. Journal of the American Medical As- 
sociation, vol. 64, no. 4, 1915. 
Hall, F. S. and E. W. Brooke, American Marriage Laics in Their Social Aspects, 

New York, Eussell Sage Foundation, 1919. 
Harmon, B., The Effects of Venereal Disease of the Parents on the Children: 

especially in relation to the production of blindness, Report of the Com- 
mission on Venereal Diseases, Final Be port of the Commissioners, London, 

1916. 
Haskell, R. H., Familial Syphilitic Infection in General Paresis, Journal of 

the American Medical Association, vol. Ixiv, no. 11, March 13, 1915. 
Hill, J. A., Comparative Fecundity of Women of Native and American 

Parentage in the United States of America, Boston, American Statistical 

Association, Dec, 1913. 
Hochsinger, K., Die gesundheitlichen Lebenschicksale erbsyphilitischer Kinder, 

Wiener Minische Wochenschrift, no. 24, June 16, 1910. 
Infant Mortality Series, No. 3, Children's Bureau Publication No. 9, Washington, 

D. C, 1915. 
Jamieson, R. C, Syphilis in Detroit as an Economic and Social Factor, Ameri- 
can Journal of Syphilis, vol. ii, no. 3, 1918. 
Jeans, P. C, Svphilis and Its Relation to Infant Mortality, American Journal 

. of Syphilis, vol. iii, no. 1, Jan., 1919. 



186 SYPHILIS OF THE INNOCENT 

Jeans and E. Butler, Hereditary Syphilis as a Social Problem, American 

Journal Diseases of Children, vol. 8, Nov., 1914. 
Journal of the American Medical Association, vol. 74, no. 9, Foreign Correspon- 
dence, Feb. 28, 1920. 
Journal of the American Medical Association, vol. 76, no. 4, Jan. 22, 1921. 
Kraepelin, E., Psychiatrie, 8th edition, vol. ii, Leipzig, Johann Ambrosius 

Barth, 1913. 
Lewinski-Corwin, E. Venereal Disease Clinics, Social Hygiene, vol. vi, no. 3, 

July, 1920. 
Lewis, Ora M., Medical Social Service as a Factor in Protective Work, National 

Conference of Social Work, New Orleans, April, 1920. 
Lewis, O. M., et al., A Clinic Studies Itself, Hospital Social Service, vol. 3, 

no. 1, Jan., 1921. 
Mimeogram, Aug., 1920, U. S. Interdepartmental Social Hygiene Board. 
Monthly Bulletin of the Boston Health Department, Boston, October, 1919. 
Nonne, M., Die heutige Standpunkt der Lues-paralyse Frage. Deutsche Zeit- 

schrift fur Nervenheilhunde, vol. xlix, 1913. 
Pusey, W. A., Syphilis as a Modern Problem, Chicago, American Medical As- 
sociation, 1915, p. 99. 
Keport of the Commission for the Study of the Question of Marriage of Syphi- 

litics, Bulletin Societe franchise de dermatologie et de syphilologie, 1920, 

translated in Venereal Diseases by Ormsby and Mitchell, Chicago, Practical 

Medicine Series, vol. vii, 1920. 
Eesolutions of All- America Conference on Venereal Diseases, Public Health 

Reports, vol. 36, no. 28, July 15, 1921. 
Boloff, B. C, The ' 'Eugenic" Marriage Laws of Wisconsin, Michigan, and 

Indiana, Social Hygiene, vol. vi, no. 2, April, 1920. 
Salmon, T. W., General Paralysis as a Public Health Problem, Proceedings of 

the American Medico-psychological Association, 70th annual meeting, Balti- 
more, Maryland, May 26-29, 1914. 
Social Hygiene Legislation Manual, 1921, Publication 312, American Social 

Hygiene Association. 
Solomon, H. C. and M. H., The Effects of Syphilis on the Families of Syphi- 

litics Seen in the Late Stages, Social Hygiene, vol. vi, no. 4, Oct., 1920. 
, A Study of the Economic Status of Forty-one Paretic Patients and 

Their Families, Mental Hygiene, vol. v, no. 3, July, 1921. 
Stokes, J. H., Today's World Problem in Disease Prevention, Washington, D. C, 

U. S. Public Health Service, Treasury Department. 
and H. E. Brehmer, Syphilis in Railroad Employees, Journal of Industrial 

Hygiene, vol. i, no. 9, Jan., 1920. 
Vedder, E. B., Syphilis and Public Health, Philadelphia and New York, Lea 

and Febiger, 1918. 
Veeder, B. S., Hereditary Syphilis in the Light of Recent Clinical Studies, 

American Journal of Medical Sciences, clii, 1916. 
Venereal Disease Legislation, Public Health Reports? No. 450, January 18, 1918. 
Weiss, R. S. and A. H. Conrad, Medical and Social Care of Syphilis at the 

Washington University Dispensary, American Journal of Syphilis, vol. 4, 

no. 2, April, 1920. 
Wigmore, J. H, Treatise on the Law of Evidence, by Simon Greenleaf, revised 

by J. H. Wigmore, Boston, Wile and Brown, 1899. 
Worthington, G. E., Developments in Social Hygiene Legislation from 1917 to 

September 1, 1920, American Social Hygiene Association, Publication No. 313. 



CHAPTER V. 

THE COMMUNITY. 

Extragenital Infection. — The social effects of syphilis dis- 
cussed in the chapter on the family also have a bearing on the 
life of the larger unit, the community. The community is 
only a network or mass of families, all interrelated by mutual 
work or play, by necessity, or by desire. One of the out- 
standing aspects of syphilis from a community point of view 
is its contagiousness by extragenital methods. An extra- 
genital chancre is one which is acquired outside of sexual 
intercourse either by chance contact or by a sexual relation 
other than coitus. 

When First Discovered. — When was it first found out that 
syphilis could be transmitted extragenitally and by chance 
contact ? Vedder 1 claims that transmission between nurse and 
suckling was established in 1504. In 1509 Seitz showed that 
surgical instruments and cupping glasses were mediums of 
infection. Cases of professional exposure were recognized 
very early. William Clowes 2 in the first treatise on "Lues 
Venerea,' ' published in the English language, 1596, says "I 
have known, not many years past, three good and honest mid- 
wives infected with this disease ... by bringing abed 
three infected women of three infected children, which infec- 
tion was chiefly fixed upon the midwives' fingers and hands." 

The first known outbreak of innocent syphilis in America 
occurred in New England in 1646 and is described in the diary 
of John Winthrop. 3 A woman is delivered of a child. She 
has a sore breast. Women and children "drew" from it 

i Vedder, E. B., Syphilis and Public Health, Philadelphia and New York, Lea 
and Febiger, 1918, p. 147. 

2 Bulkley, L. D., Syphilis in the Innocent, New York, Bailey and Fairchild, 
p. 175, quotes' H. Lee, Lectures on Syphilis, Philadelphia, 1875, p. 35, who quotes 
Clowes. 

3 Lane, J. E., A Few Early Notes on Syphilis in the English Colonies of 
North America, Archives of Dermatology and Syphilis, vol. 2, no. 2, Aug., 1920. 

187 



188 



SYPHILIS OF THE INNOCENT 



and 16 persons were infected with "lues venerea." The hus- 
band was thought to have infected his wife. "Though many 
did eat and drink and lodge in bed with those who were in- 
fected . . . none took it of them but by copulation or 
sucking. ' ' 

Incidence of Extragenital Infection. — The seriousness of ex- 
tragenital infection from a community aspect lies in its in- 
cidence in comparison with genital infections. Bulkley 1 made 
a complete study of such cases and submitted the following 
table: 



Table 32. Proportion of Extragenital to Genital Chancres 



02 
O 

g 

13 
O 

j 

a 
« 
a 

2 
a 
> 


Bassereau, Robert, Four- 
nier and Lefort, Hopital 
du Midi, Paris 


°© » 

S3 

— 

55 

<o © 

E c 

. ©"Sf* 

u 


Carriere, Burlet, Nodet, 
H6p. Antiquaille, Lyons 


Sigmund, Mragek, Zeissl, 
Allg. K. K. Krankenhaus, 
Vienna; Lang, Inns- 
bruck 


Pellizzari, R. Arcesped. d. 
S. Maria Nuova.Florence; 
Breda, Padua; and Di- 
Lorenzo, Naples 


11 

© O OS 

Hi 

-2 c 
cos 

oo M) © 

© 


< 
o 
t- 1 


Total Cases 


1513 


633 


248 


1860 


602 


2267 


7123 


Genital 


1445 


596 


219 


1732 


548 


2230 


6770 


Extragenital 


68 


37 


29 


128 


54 


37 


353 


Lips 


38 


20 


16 


76 


19 


15 


184 


Breast 




1 


9 


7 


22 


2 


41 


Hand 


3 






29 




1 


33 


Tongue 


8 | 2 




5 


2 




17 


Throat 


... | 3 




8 


3 


2 


16 


Nose 


1 


3 


3 


1 






8 


Chin 


6 






1 






7 


Eyelids 


2 


1 


1 


1 


1 


1 


7 


Cheek 


2 








. . | 3 


1 


6 


Buccal Cavity 


1 


4 






,.| -, 




6 


Neck 




1 






.. | 




4 


Forehead 


1 


2 






.. 1 ... 




3 


Unclassed 


6 










15 


21 



i Bulkley, op. cit., p. 25. 



THE COMMUNITY 



189 



Thus of a total of 7123 cases, 353 or 5 per cent were extra- 
genital. As these figures are taken from clinics where most 
people go for syphilis acquired by intercourse and as the 
many cases which appear at special eye, throat, skin clinics, 
etc., are not included, Bulkley feels that 10 per cent is a fairer 
estimate. 

Dr. H. W. Porter 1 made a statistical study of extragenital 
chancres among the patients at the Washington University 
Dispensary. One hundred and six cases of chancre were 
found from September, 1916, to August, 1919. Thirteen or 
11.3 per cent of the total primary sores were extragenital. He 
also gives the following table from Montgomery: 

Table 33. Cases of Extragenital Chancre 

" Physicians Making Report Pee Cent 

Krefting (Christiania) 15.6 

Fournier (Paris) 9.0 

Von Broich, Bonn (Germany) 9.0 

Van Walsen (Amsterdam) 8.5 

Mracek (Vienna) 7.5 

Bulkley (New York) 5.5 

Montgomery (California) 5.5 

Finger (Vienna) 1.3 

Pnsey 2 quotes Nichols as giving the amount of extragenital 
infections for the army as 6 to 7 per cent. Dr. C. M. Smith 3 
estimates that at least 10 per cent of the primaries seen at the 
Massachusetts General Hospital syphilis clinic are extra- 
genital. He considers 12 per cent a conservative estimate and 
feels that 15 per cent would be even more correct. The large 
majority of these chancres were innocently acquired. Dr. 
Smith is thoroughly convinced that lip and mouth chancres 
resulting from perversions are extremely rare. Practically 
all lip and mouth chancres are from kissing. Dr. Smith's 
estimate is thus larger than most of the percentages worked 
out in the above tables. 

i Porter, H. W., Statistical Study of Extragenital Chancres. Archives of Der- 
matology and Syphilology, vol. 38, N. S., vol. 1, no. 1, pp. 15-24. 

2 Pusey, W. A., Syphilis as a Modern Proolem, Chicago, American Medical 
Association, 1915, p. 112. 

3 Personal communication. 



190 SYPHILIS OF THE INNOCENT 

One can safely say that 10 per cent of the chancres are ex- 
tragenital. It is impossible to get closer to the real incidence 
of extragenital innocent chancres. Patients often refuse to 
tell how the chancres were acquired. All the cases in the 
literature have been analyzed by Bulkley 1 up to 1892; by 
Munchheimer from 1892-1896 and by Scheuer 2 from 1896-1909 
but as we have no norm of the total number of syphilitic cases 
of all kinds, this does not aid much in determining the in- 
cidence. Extragenital chancres are more common in women 
than in men as the former are more exposed as midwives, 
attendants, wet nurses, and mothers of babies who have ac- 
quired syphilis accidentally. 

Less Extragenital Syphilis Than Formerly — Early Epi- 
demics. — There is less syphilis transmitted extragenitally 
than formerly. The following quotations from Bulkley 1 of 
epidemics of syphilis among the innocent in the early days of 
the disease are typical and interesting: 

In 1599 in Nuremberg, Germany, according to the records in the 
town archives, over 70 people were infected by the carelessness of 
the town cupper. 

In 1727, in Euphemia, France, a midwife, first herself infected 
digitally, transmitted syphilis to 50 parturient women together with 
30 of their families. 

In 1826, in Prussia, a strange nursling, the bastard of a soldier, was 
brought to the village by its mother who could not nurse it. A 
nursing mother suckled it and 23 more were infected. 

In 1861, in Italy, 80 were directly infected by vaccination, of which 
40 were children and 26 nursing women. 

In 1866, in South Carolina, Jones and Foster reported that 150 
people of all ages, who were vaccinated from a syphilitic woman, 
presented a vaccine chancre. 

In 1878, in Philadelphia, Maury and Dulles reported 15 soldiers 
infected by a syphilitic tattooer. 

1 Bulkley, op. cit., pp. 115-122. 

2 Scheuer, Die Syphilis der Vnschuldigen, Berlin, Urban and Schwarzenberg, 
1910, quoted by Vedder, p. 148. 



THE COMMUNITY 



191 



Methods of Extragenital Transmission. — Bulkley 1 gives the 
following table demonstrating the possible transmission of 
innocent syphilis in epidemic form as shown above, through 
domestic and social relations, industrial contacts, the nutri- 
tion of or attendance on infants, and the care of the sick by 
surgeons, dentists, attendants, etc. 









Table 34 








From cupping 








From breast drawing 








From hand raising 








of infants 




A 




From lactation 




Syphilis 




From accouchement 




Pandemica 




From circumcision 
From vaccination 
From eating and 




I 




drinking and domes- 




Syphilis 




tic propagation 




Epidemica 




From tattooing 
From glass blowing 
From eustachian 

catheterization 
From application of 

tongue to eye 








1. Eating and f 1. Implements 


and 






drinking, ( vessels 








and use of 1 2. Tobacco, troches 






tobacco [ etc. 










1. Wearing apparel, 






2. Personal 


etc. 








and house- 


2. Bedding 








hold 


3. Toilet articles 




■ 


effects 


4. Miscellaneous 




1. Domestic 




articles 






and social 




/ 1. Kissing 




trans- 


3. Active and f 1. Buccal 


i 2. Biting 




mission 


temporary -j 

contact ( 2. Digital 


f 1. By contact 






\ 2. By nail 


B 






I wounds 


Syphilis 








Sporadica 








• 




| 4. Passive contact 


/ 1. In sleep 


I 






2. In carrying 


Syphilis 








Economica 


2. Industrial 


1. Buccal 


1. By occu- 
pation 
requiring 
use of 
mouth 


f 1. Glassblowers 
(pipes) 
2. Musicians 
! (wind instruments) etc 




trans- 




2. By nec- 


1. Cooks (tasting 




mission 




essary or 


spoons) 
2. Flowermakers 








unneces- 








sary use 


(needles) etc. 




1 




of lips 






I 


2. Digital ( By sub- 


1. Laundresses 
[ etc. 






1 stances 






1 infpcting 










fingers 





l Bulkley, op. cit., p. 17. 



192 



SYPHILIS OF THE INNOCENT 









1. Nurse in- 












fected by 








1. By lac- 


nursling 






1 . Acquired 


tation 








through 










nutrition 




2. Nursling 






of infants 




infected 
by nurse 
or by 
another 




B 






nursling 




Syphilis 










Sporadica 




2. By hand- 


1. Adults 




(Continued) 




feeding 

of infants < 


infected 




II 






2. Infants 




Syphilis 






infected 




Brephotrophi- 
ca 




1. Mediate 


f 1. Toilet articles 
\ 2. Covering 








contact 






2. Acquired 


with soiled 








through 


articles (in- 








attendance 


fant alone 








on infants 


infected) 

2. Direct 
contact 


1 . Active f 1 . Buccal 
limited ] 2. Digital 
contact [ 3. Aerial 








■ 










2. Passive 


1. Parturition 










contact 


2. During slumber 
in bed 

3. By contact in 
arms 












i' 1 . Surgeons 
| 2. Accouch- 






1. Unnecessary 






• 


exposure 


1. Manual 


•j eurs 
1 3. Dentiata 




1. Operator 








victim 


2. Necessary 
exposure 


/ 1. Buccal 
, 2. Cephalic \ 2. Facial 


[ 4. Attendants 












2. Operator 


1. Direct 


1. Digital f 1. Infecting [ 1. Chirurgi- 
contact \ finger seat | cal mani- 






syphilifer 


contact 










[ of chancre ; pulations 










) 2. Obstetri- 










cal mani- 




B 






{ pulations 




Syphilis 










Sporadica 






[ 2. Infecting 




(Continued) 






1 finger 
1 soiled by 












III 






[ saliva, etc. 




Syphilis 










Technica 




2. Instru- 
mental 
contact 


2. Buccal { 1. With a wound 
contact \ 2. Without a 
[ wound 

[ Instruments soiled 
< with operator's 
[ saliva 






3. Operator 


1. By trans- 


f 1. Solid sub- 






medium 


plantation 


i stances 








and in- 


1 2. Liquid sub 






. 


oculation 


l„ stances 








[ 1. Cutting [ 1. Wound acci- 






2. By unclean 


instru- J dental 








instru- 


ments ] 2. Wound 

[ intentional 








ments 








1 


[ 2. Blunt instruments 








1 3. By unclean 


/ 1. In suspension 








[ substances 




\ 2. On bandages 





We would support Vedder's criticism of this table that 
many of the methods of transmission there given are now so 



THE COMMUNITY 193 

rare and infrequent that they no longer materially affect the 
public health. However they are indicative of the possible 
virulence of this phase of the spread of syphilis before the 
days of proper control. 

Scheuer 1 has tabulated the method of transmission in 
14,590 extragenital chancres occurring from January 1, 1896 
to January, 1909, including all cases in which the method of 
transmission was known. Vedder subdivided this table into 
groups as follows : 

Table 35 

GROUP 1. BUCCAL CONTACT No. Per Cent 

Kissing 192 

Instruments used in certain callings, such as glass- 
blowers, musicians, and chemists 37 

Smokers 1 articles 28 

Drinking glasses .... 26 

Eating utensils 22 

Toothpicks 5 

Artificial feeding of children 10 

Total 320 22.07 

GROUP 2. PATIENTS INFECTED BY PHYSICIANS 

Vaccination 272 

Infected instruments 46 

Total 318 21.93 

GROUP 3. ACQUIRED THROUGH MEDICAL ATTENTION TO PATIENTS 

Physicians 168 

Midwives 64 

Nurses 17 

Unlicensed physicians 8 

Volunteer nurses 6 

Total 263 18.13 

GROUP 4. ACQUIRED THROUGH CARE OF SYPHILITIC CHILDREN 

Nursing .^ 169 

General care and handling 91 

Total 260 17.93 

l Scheuer, Die Syphilis der Vnschuldigen, Berlin, Urban and Schwarzenberg, 
1910, quoted by Vedder, pp. 150-157. 



194 SYPHILIS OF THE INNOCENT 

GROUP 5. TRANSMITTED TO OTHER MEMBERS OF FAMILY BY 
CLOSE FAMILY ASSOCIATION 

No. Per Cent 

Personal contact 36 

Common use of toilet articles, medicine, 

etc 32 

Handling of clothing, wash, etc 17 

Sleeping with syphilitic 11 

Play, games, etc 5 

Total 101 6.96 

GROUP 6. MINOR OPERATIONS PERFORMED BY NON-MEDICAL MEN 

No. Per Cent 

Barbers and shaving utensils 44 

Tattooing 18 

Circumcision 7 

Total 69 4.75 

GROUP 7. MISCELLANEOUS 

Contact with finger 45 

Biting 41 

Insect bite (?) 1 

Total 87 6.00 

GROUP 8. UNNATURAL SEXUAL PRACTICES 

Total 32 2.20 



Consideration of this table . . . shows that immediate or medi- 
ate buccal contact with syphilitics is the most frequent method of 
extra-genital transmission. . . . The great danger of kissing is 
. . . emphasized by the fact that 192 infections, or 13.24 per 
cent of the total, were definitely known to be transmitted in this way, 
. . . this is certain to be an underestimate. 

Group 2 affords the greatest and most painful surprise. It appears 
from this that no less than 21.92 per cent of the total number of 
infections considered, were transmitted to the patients by physicians, 
mostly by vaccination. Vaccination at the present day in this country 
is not responsible for so many infections whatever may be the case in 
certain parts of Europe. However, the number of patients infected 
by physicians, according to Scheuer, points a moral as to the necessity 
for scrupulous care in the disinfection of instruments. 

Group 3 indicates clearly the great danger to which plrysicians and 
attendants are constantly exposed, and needs no further comment. 



THE COMMUNITY 195 

Neither does the great danger of handling syphilitic children require 
further discussion ; the figures show that 17.93 per cent of the total 
infections were transmitted in this manner. 

Reasons Why Extragenital Syphilis Is Not More Frequent 
— Wet Nurse Directories. — The question arises why more per- 
sons do not acquire syphilis in any one of these ways. Syphilis 
is no longer so commonly spread through chance contact. 
The stage of dirty medical instruments, careless vaccination, 
etc., has passed. The earlier writers greatly emphasized the 
danger of infection through midwives and wet nurses. "We 
now, in 1922, have laws controlling the practice of midwives. 
Women no longer act as wet nurses to chance children nor are 
w-et nurses accepted in a family without thorough examina- 
tion. The Infants' Hospital Registry for Wet Nurses, Bos- 
ton, is an example of the new system. 

The effort was first made in Boston to run a registry simi- 
lar to an employment agency. This was found to be unsatis- 
factory as a registry must be affiliated with charitable and 
social organizations in order to maintain the supply and with 
some hospital in order to secure adequate medical examina- 
tion. At the present time the Boston registry is under the 
auspices of the Peter Bent Brigham and the Infants' Hospi- 
tals. Complete laboratory examinations are made on all 
women irrespective of w T hether such examinations have pre- 
viously been made elsew T here. Careful physical examinations 
are also made. This w 7 et nurse directory has supplanted 
other means of obtaining wet nurses in the city. Thorough 
medical examination obviates the chance of a syphilitic 
woman acting as a wet nurse. 1 

Short Life of Treponema. — Another fact which makes 
chance infection more uncommon than one might expect is 
the short span of life of the germ of syphilis on inanimate 
objects, and the necessity for the correct soil in the human 
body. The chief method of spread is direct contact with a 
moist open lesion. Most authorities feel that an abrasion of 
the skin is necessary for a person to become infected, although 

l Monthly Bulletin of tlie City of Boston Health Department, Sept., 1919. 



196 SYPHILIS OF THE INNOCENT 

Vedder thinks that the germ may penetrate the unbroken 
mucous membrane. 

Numerous experiments have been made to show the span 
of life of the treponema on dry material such as razors, combs, 
drinking and eating utensils, toilet seats, and the like. Gas- 
ton and Comandon 1 allowed patients with lip chancres or 
mucous patches containing treponemata to drink from water 
glasses. These were then rinsed and examined for the or- 
ganisms, which were found alive until the saliva containing 
them had dried, which was about one-half hour. Hertmanni 2 
found that it took small drops of saliva containing tre- 
ponemata 15 to 45 minutes, and larger drops one to one and 
one-half hours to dry, at the end of which time the organisms 
were dead. 

Treponemata can live only a relatively short time ex- 
posed to the air as they are anaerobic organisms, and, as the 
foregoing references indicate, they need moisture. Browning 
and Watson 3 report that towels contaminated by a culture of 
treponemata and kept moist but exposed to diffuse daylight 
remained alive for 11% hours. They are very easily killed 
by changes of temperature. Neisser 4 found that they lost 
power of infection after three hours at 10° C (50° F) and one- 
half hour at 48° C (118.4° F) while Mucha and Landsteiner 5 
state that they die in 5 to 6 hours at 20° to 27° C (68° to 
80.6° F) and in fifteen minutes at 45° C (113° F). 

The treponemata are readily killed by antiseptics. From 
the practical standpoint Pusey 6 states that the limit of life for 
the treponema on an inanimate object is 8 to 10 hours, and 
that material from chancres, even when kept moist, is virulent 

1 Gaston and Comandon, Preuve donne par 1 'ultra microscope de la con- 
tagion possible de la syphilis par les verres a boire, Bulletin de la Societe 
Franchise de Dermatologie et Syphilologie, 19, 1908, p. 292, quoted by Vedder, 
p. 122. 

2 Hertmanni, Beitrage zur Lebensdauer der Spirocheta Pallida, Dermatologische 
Zeitschrift, xvi, 1909, 633, quoted by Vedder, p. 122. 

3 Browning, C. H., and D. Watson, Venereal Diseases, A Practical Handbook 
for Students, with an introduction by Sir John Bland-Sutton, New York, 
Oxford University Press', 1919, p. 9. 

4 Vedder, op. cit., p. 123, quotes Neisser. 

5 Mucha and Landsteiner, Zur Technik der Spirochaetersuchung, Wiener 
Minische Woclienschrift, vol. xix, 1906, p. 1349, quoted by Vedder, p. 123. 

6 Pusey, op. cit., p. 110. 



THE COMMUNITY 197 

for 6 to 10 hours only. Stokes 1 thinks the germs are capable 
of infecting for not more than 6 to 7 hours when on ordinary 
objects and then only when they are moist. 

Most Bodily Fluids Not Infectious. — Saliva and sputum 
are the bodily juices that are most important from the stand- 
point of the mediate transfer of the treponema through the 
agency of objects. Sweat, milk, urine, spinal fluid, and the 
like have little practical bearing as sources of infection. 
Blood, however, may be the medium of transfer of acci- 
dental infections. This is especially true in relation to physi- 
cians, dentists, nurses, and midwives. A needle prick re- 
ceived during surgical procedures is the most to be feared. 

How to Avoid Infections — Greater Cleanliness. — Increased 
care may still be advised to doctors, medical attendants, and 
nurses. All articles used by them should be sterilized and 
their hands should be protected. All those working as mid- 
wives, tattooers, barbers, should be thoroughly examined 
and licensed. 

Less Kissing. — As the most frequent location for the ex- 
tragenital chancre is the mouth, prophylaxis is directed 
towards it. Promiscuous kissing should be avoided as far as 
possible. Kissing is the most common way of infecting the 
innocent friend, fiancee, wife, or child. A mother who allows 
any newcomer to kiss her baby, a girl who ' ' flirts ' ' very freely, 
runs serious risks of infection. Stokes 2 is particularly em- 
phatic on this point: 

Syphilis in particular does not wait for sexual intercourse in order 
to attack the lax and careless. Those who permit liberties to be taken 
with their persons hi the form of kissing and caresses which do not 
go to the point of actual sexual relations, are subject to a risk of 
infection which is larger than is generally realized. This risk is 
doubled by the mistaken belief of both parties that by indulging in 
mild offenses they escape the dangers of an outright breach of decency. 

1 Stokes, J. H., The Third Great Plague, Philadelphia and London, W. B. 
Saunders Co., 1917, p. 113. 

2 Stokes, J. H., To-day's World Problem in Disease Prevention, Washington, 
D. C, issued by the U. S. Public Health Service, Treasury Department, 1919, 
p. 119. 



198 



SYPHILIS OF THE INNOCENT 



Schamrerg's Famous Case of an Epidemic From a Kissing Game 

(M) 

(22) 

with lip chancre 







kissed 










infested.-*- 




«-i 




i 


-escaped infection 


1 T— J ■- i 

III! 
till 

(20) (18) (19) (16) 
f f » t 


T" 
i 


■ i 
• i 

i) i\ 




— j .. 

i 
t 

(F) 


i 
• 

(F) 


, K-, 1^ 

1 1 1 

(F) (F) (t) 


L_J 1 II 1,1 || 


4j 





one of whom 
infected a 
oo-*orkar 
through chance 
contact of in- 
feoted object 


age i 


one of whom 
kissed 

(M) 


W/)//A 




<M) - male + at 
(F) - female + 


I - developed lip chancre 


g^$3 - developed chancre of oheek 



Avoidance of Articles Used by Syphilitics.— Contagious 
sores often come to syphilitics who smoke a great deal. Peo- 
ple must be trained never to put in their mouths articles used 
by others. This applies to pipes, cigars, spoons, cups, musi- 
cal instruments, workmen's tools, etc. The public-health ap- 
proach to this has been the establishment of public spouting 
drinking fountains, the general use of paper cups and towels 
in offices, hospitals, schools, etc. 

The possibility of exchange of syphilis between wet nurse 
and child can be prevented by the establishment of more ade- 
quate wet nurse directories as mentioned before and by care 
that a syphilitic child should be suckled not by a healthy but 
by a syphilitic nurse. The families w r ho employ wet nurses 
must not only demand a healthy woman for their healthy 
children but must insure protection to such a woman if there 
is the slightest question of syphilis. 

Treatment as Preventive Measure. — Increased effort must 
be made to locate the source of each new infection so that 
treatment may prevent further accidental contact. 

Of course the important preventive measure of extra- 
genital as well as genital syphilis is treatment of the syph- 
ilitic with active lesions. Everv effort must be made to in- 



THE COMMUNITY 199 

sure enough treatment to render a person noncontagious to 
the public. It is again evident that the follow-up of patients 
is important as are the efforts of all state boards of health to 
whom contagious cases not under treatment are reported by 
name. 

The question of the homeless young man with a contagious 
sore on the lip, hands, face, etc., has not been met. For in- 
stance, if a patient reports to the clinic with a contagious 
chancre of the lip and is admittedly of the wandering type, 
one cannot be sure that he will observe necessary care to 
avoid infecting others. He may sleep at one lodging house 
one night and at another the next night. He may refuse to 
observe necessary caution in the matter of eating and drink- 
ing at different restaurants. If he does not report to the 
clinic for the next treatment, the worker only too often finds 
that he has departed from his last address leaving no trail 
behind him. 

Control of Travel. — There is legal authority to control the 
travel of known contagious patients, it being stated in the 
Chamberlain-Kahn Bill 1 that one of the duties of the Division 
of Venereal Diseases of the Public Health Service is "to 
control and prevent the spread of these diseases in interstate 
traffic. ,, Amendment 7 of the interstate quarantine regula- 
tions prohibits the travel of persons with venereal diseases, 
and state boards of health in 47 states have agreed that they 
should have definite regulations — conforming to interstate 
regulations — controlling travel within the state. Unfortu- 
nately, these laws are rarely evoked. 

Examples of Extragenital Infection.— Bulkley 2 gives a 
series of interesting cases of extragenital infections, of which 
we will quote some of the most striking: 

I. Infection in Domestic Life. 

1. From eating out of the same utensils. 

A workman shared his drinking glass with a comrade who had 
a chancre on the lip and got a lip chancre (Pellizzari, Pisa, 1879). 

1 Pierce, C. C, and H. F. White, Lessons Taught by Measures for Control of 
Venereal Diseases, Journal of the American Medical Association, vol. 75, no. 17, 
Oct. 23, 1920. 

2 Bulkley, op. cit., pp. 144-155. 



200 



SYPHILIS OF THE INNOCENT 



A lady got a chancre of the lip from carrying in her mouth 
a spoon used by a syphilitic cook (Rollet, 1861). 
2. From wearing apparel. 

A patient had itching and fissure between the nates. He went 
bathing in a strange suit of bathing clothes and scratched through 
the bathing suit. An ulcer formed a few weeks later. 

II. Infection in Industrial Relations. 

1. The entire family of a weaver in Berlin became infected by all 
the members using the same tube in the mouth for sprinkling cloth 
(F. J. Behrend, Syphilidologie, Leipzig, 1839-46). 

2. A servant girl contracted syphilis through a speaking tube in a 
hotel. (Guignard, Paris, These de Paris, 1882, No. 97, Contribution a 
l'etude des chancres syph. extragen. Case of Martineau). 

III. Case of Innocent Infection by Child. 

Infant syphilitic nursling (died of disease) 
infects 

Madame X (who aborts) 
infects 



l 

I 
Infant P 
infected 

\ 

Mme. P. (who 
aborts) infected 

1 
I 

Husband (chancre 
on penis) 



l 

l 
Infant M 
infected 



Mme. M. (who 
aborts) infected 



Husband 



Infant Y 
infected 



Mme. Y. (who has 
stillborn child) 
infected 

I 
Husband 



I 

l 
Her 
Husband 



Mme. X's child had died of syphilis and she nursed these children 
to ease her breast (Dron, Achille, 1879). 



Similar cases may be given from other authorities. 

A healthy woman nursed a healthy child. Then she nursed a 
syphilitic child, acquired syphilis, and bore a syphilitic child 
(Bertherand 1 ). 

i Diday, P., Treatise on Syphilis in Newborn Children and Infants at the 
Breast, translated by D. Whitley with notes by F. R. Sturgis, New York, Wm. 
Wood and Co., 1883, quotes Bertherand, p. 25. 



THE COMMUNITY 201 

A girl of 16 had general syphilitic roseola and sore throat. She 
denied intercourse and was fonnd to be a virgin. She had a small 
cicatrix on the right forearm. She had been carrying a baby without 
a napkin on her bare right arm. The baby had mucous patches on 
the anus (Van Buren and Keyes, 1877 1 ). 

A man gave a history of slipping on the street twenty years pre- 
vious. He grazed the back of his hand and a bystander, anxious to 
aid, applied to the open wound a piece of sticking plaster which he 
had moistened with his saliva. Three or four weeks later a chancre 
developed at the site of injury. 1 

Some of the recent cases under observation show similar 
infections in home, social, and industrial life. 

Case 129. Philip Neilson undoubtedly infected his brother by 
sleeping in the same bed with him when he was in a contagious stage 
of syphilis. 

Case 130. Frances Newton had a lip chancre as a result of kissing 
her fiance. 

Case 131. Jack Forman, a three-months baby, had a chancre on 
the eyebrow. The mother and father were perfectly healthy. It was 
thought that the child was infected by some syphilitic relative who 
kissed it. 

Case 132? A nursing baby was infected by an infant relative. 
The baby in turn infected the mother, who appeared at the clinic with 
a breast infection which was diagnosed syphilis. 

Examples of Escape of Infection. — Obviously the above 
series of cases do not indicate that whenever there is a possi- 
bility offered in the home or at w T ork for syphilis to be trans- 
mitted extragenitally, an infection actually takes place. Often 
when it seems most likely that infection wall occur, the family 
or co-workers escape. 

Case 133. Mr. Bryant arrived at the clinic with secondary mani- 
festations of syphilisr He had had a swelling and soreness of his 

1 Shillitoe, A., The Primary Lesions and Early Secondary Symptoms as Seen in 
the Female, (A System of Syphilis, vol. 1), London, Frowde, Hodder and 
Stoughton, 1914, second edition, p. 245, quotes Van Buren and Keyes, 1877. 

2 Department of Medical Social Work, Boston City Hospital Report, Feb. 1, 
1919. 



202 SYPHILIS OF THE INNOCENT 

tongue for about eight weeks which had been recalcitrant to the 
treatment applied. Having no intimation of the syphilitic condition 
he had used no precautions. Although he was at the height of the 
most contagious period, with all the conditions in this case seeming 
to favor the transmission to one or both, neither the mother nor child 
showed any evidence of infection. 

Case 134. Stanley Bliss was an attractive boy of four years who 
was brought to the clinic because of an eruption on his body which 
was found to be a symptom of secondary syphilis. The remains of a 
chancre were on his chin. Although it was not possible actually to 
trace the origin of the chancre, it seemed probable that he obtained 
it from one of his relatives with whom he was staying for a time. 
Neither parent acquired the infection from the child, although they 
cared for him after the development of symptoms and during the 
most contagious stage. 

Case 135. On the death of James Dolan's 1 mother a friendly 
neighbor undertook to care for him. She brought him to the clinic 
at two months of age. He was found to be in a contagious stage of 
syphilis. The woman, although she had had the closest contact with 
the child, escaped infection. 

Case 136. Helen Laforee had an active contagious syphilis discov- 
ered through the illness of her two-months old syphilitic child. She 
was working in a restaurant. As far as known, she had not infected 
anybody. As soon as the diagnosis was made she was immediately 
discharged from work. 

A good group of cases exemplifying the possibility of ex- 
tragenital contamination in the home and industrial life is 
given by Blaisdell. 2 Although the conditions were excellent 
for further contamination, in only one of the cases was there 
known extragenital infection. Of course it may be that if 
there had been a more complete follow-up of all possible con- 
tacts, more cases would have turned up. The group illus- 
trates, however, the above point, that a possibility of extra- 
genital infection by no means indicates an actual infection. 

1 Children's Hospital, Boston. 

2 Blaisdell, J. H., The Menace of Syphilis to the Clean-Living Public, Boston 
Medical and Surgical Journal, vol. clxxii, no. 4, April 1, 1915, pp. 476-483. 



THE COMMUNITY 



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204 SYPHILIS OF THE INNOCENT 

Often, of course, cases of syphilis are apparently contagions 
while there is really no danger. This is especially true in 
various industrial pursuits. 

Case 137. Mr. Frank was a syphilitic baker. There was, however, 
no danger of infection to others. In the first place, the infection was 
in a chronic stage. Furthermore, he had no open lesions and accord- 
ing to the history had never had any. Thirdly, the time that elapses 
between the baking of breads and cakes and the eating is so long that 
there is no reasonable fear of the treponema living long enough to 
infect the consumer. 

Case 138. Etta Prince was a syphilitic of 22 who had been infected 
five years previously. Her employer was aware of her infection and 
when an eruption appeared on her hands at once feared that she 
might be a menace to her fellow employees. Examination showed 
that although the girl was a syphilitic she was not contagious in any 
way and the rash was of an eczematous character. 

Case 139. Boston Dispensary Case. 1 A young syphilitic girl 
secured a position in a restaurant folding linens. She feared that 
her occupation might endanger others. She had recently acquired 
syphilis but was no longer contagious as she had received adequate 
treatment, as far as the present stage of the disease was concerned. 
Permission was given her to retain her position. 

If people who might be the source of innocent infections 
were 100 per cent contagious very many more individuals 
would be infected by contact with the many syphilitics in 
occupations bringing them into close association with others. 
It is impossible to decide what factors determine the spread of 
innocent syphilis in industry. We cannot put the danger on 
a percentage basis. However, it is apparent that the danger 
is not quite as great as many people would think or undoubt- 
edly more extragenital cases would appear at hospital clinics 
with a history of infection acquired through occupation. The 
Lakeside Hospital, Cleveland, investigated 285 syphilitic 
cases, including many contagious ones and listed the occupa- 
tions as nearly as possible in order of their danger to the pub- 
lic from the standpoint of infections innocently acquired. 
Practically one fourth were employed at work involving close 
contact with people, food, clothes, etc. 

i Reported at a meeting. 



THE COMMUNITY 205 

111 this connection we made a study of 755 paretics to find 
out how many of them were in occupations usually supposed 
to be dangerous to the community. The following groups 
were selected, and it was found that 154, or 20.3 per cent of 
the paretics were working in these occupations. The number 
and per cent in each group were as follows: 

No. P. C. 

People handling food 67 43 . 50 

Domestics 47 30.51 

Laundry Workers 3 1.94 

Clothing Workers 15 9 . 74 

Barbers 9 5.84 

Physicians and Dentists 5 3 . 24 

Musicians 6 3 . 89 

Druggists 2 1.29 

If the idea that all syphilitics are contagious were true the 
fact that 20 per cent of a random group of late syphilitics 
were working in occupations which brought them into close 
touch with others would be indicative of many other infected 
cases. As a matter of fact, paretics and most other syphilitics 
in the late stages are not contagious to others and therefore 
the general public need not be aroused at the idea of so many 
syphilitics in the above occupations. On the other hand, 
many of these patients were in all likelihood employed in the 
same occupations at the time they acquired syphilis and were 
in the most contagious period of the disease. Thus, the im- 
portant point is not whether the person is syphilitic but 
whether he is in a contagious state. 

Incidence of Syphilis and its Financial Results. — One of 
the most outstanding effects of syphilis on the community is 
the direct financial cost in dollars and cents. In every com- 
munity there is a certain definite yearly outlay of money for 
the care of syphilitics. Very few estimates of the exact cost 
have been computed. In order to know what the actual cost 
is, one should know something about the prevalence of the 
disease. Frequent estimates based largely on Wassermann 
surveys have been made indicating that somewhere between 
10 and 15 per cent of the community at large are infected with 



206 



SYPHILIS OF THE INNOCENT 



syphilis. A consideration of these figures does not clearly 
show the amount of syphilis in the community because of the 
great variation to be found in different groups. The accom- 
panying table illustrates the difference in the percentages, 
which vary from a fraction of 1 per cent in a group of healthy 
young American men who were applicants for commissions 
in the Aviation Corps to 97 per cent in a group of prostitutes, 
with intermediate figures of approximately 4 per cent for 
some groups of pregnant women to 35 per cent in criminal 
groups. 



Table 37. Variation in Estimates of Prevalence of Syphilis in 

the Community 



Clinic 


Group 


Indi- 
viduals 


Positive 

Wassermann 
Reaction 








No. 


P.C 


Mass. State Department of Health 1 


Aviation Corps 


3701 


21 


0.56 


New England Hospital for Women and 
Children, Boston 2 


Special Hospitals or Clinics for 
Women 


2090 


52 


2.48 


Women's Diseases, Private Cases, Wash- 
ington 3 


Special Hospitals or Clinics for 
Women 


417 


17 


4.07 


Women's Clinic, Washington* 


Special Hospitals or Clinics for 
Women 


150 


13 


8.66 


Columbia Hospital for Women, Wash- 
ington* 


Special Hospitals or Clinics for 
Women 


188 


21 


11.17 


Gynecological Clinic, Philadelphia 6 


Special Hospitals or Clinics for 
Women 


300 


36 


12. 


Dr. Huron W. Lawson, Washington 7 


Candidates for Police Force 


856 


54 


6.3 


Lying-in Hospital, New York 8 


Pregnant Women 


2000 


61 


3.05 


Maternity Department, University of 
Michigan Hospital, Michigan 9 


Pregnant Women 


381 


18 


4.7 



1 Hinton, W. A., Specific Inhibitory Eeaction of Cholestrinized Antigens in 
The Wassermann Test, American Journal of Syphilis, St. Louis, vol. 5, no. 1, 
Jan., 1921, p. 7. 

2 New England Hospital for Women and Children. Tests by Massachusetts 
State Department of Health, compilation by H. C. Solomon, Boston, Mass. 

3 Vedder, op. cit., p. 67. Private Cases. 

4 Vedder, op. cit., p. 67 gives statistics from Women's Clinic, Washington. 

5 Vedder, op. cit., p. 67 gives statistics from the Columbia Hospital, Wash- 
ington. 

6 Williams and Kolmer, The Wassermann Eeaction in Gynaecology, American 
Journal of Obstetrics, lxxiv, 1916, p. 639, quoted by Vedder, p. 66. 

1 Vedder, op. cit., p. 81, quotes Dr. Huron W. Lawson, Washington, D. C. 

8 Dr. Losee, Syphilis in Mother and Infant, Bulletin of the Lying-in Hospital 
of New York, June, 1916, quoted by Vedder, p. 84. 

9 Dr. Peterson, Observations on the Occurrence of Syphilis in the University 
of Michigan Obstetric and Gynaecologic Clinic, Surgery, Gynaecology, and Obstet- 
rics, 1916, p. 280, quoted by Vedder, p. 59. 



THE COMMUNITY 

Table 37 — Continued 



207 



Clinic 


Group 


Indi- 
viduals 


Positive 

Wassermann 

Reaction 




No. 


P.C. 


Mass. State Dept. of Health tests on 
pregnant women 3 " 


Pregnant Women 


172 


8 


4.7 


Florence Crittenton Home, Boston 11 


Pregnant Women 


192 


11 


5.72 


Lying-in Hospital, Boston 1 * 


Pregnant Women 


4935 


290 


5.87 


Pregnancy Clinic, Brooklyn 13 


Pregnant Women 


892 


70 


7.9 


Obstetric Cases at Clinic, Brooklyn 14 


Pregnant Women 


1822 


145 


8. 


Pregnancy Clinic, Chicago 16 


Pregnant Women 


146 


14 


9.5 


Obstetric Cases at Sloane Hospital for 
Women, New York 1 * 


Pregnant Women 


2488 


227 


9.1 


Maternity Hospital, Belfast 17 


Pregnant Women 


171 


22 


12.8 


Maternity Clinic, Seclin 18 


Pregnant Women 


103 


16 


15.5 


Obstetric Cases, Washington, D. C. 19 


Pregnant Women 


201 


36 


17.06 


East Louisiana Hospital for Insane, 
Louisiana 20 


Insane W'omen 


516 


20 


4. 


Pennsylvania Hospital for Insane, Phila- 
delphia 21 


Insane Women 






6.5 


State Hospitals, Michigan 23 


Insane Women 






6.65 



io Vedder, op. cit.. p. 61, quotes Massachusetts State Department of Health 
for 1915. 

11 Florence Crittenton Home, Boston. Tests by Massachusetts State Depart- 
ment of Health, compiled by H. C. Solomon, Boston. 

12 Lying-in Hospital, Boston, Tests by Massachusetts State Department of 
Health, compilation by H. C. Solomon, Boston. 

13 Jeans, P. C, Syphilis and Its Relation to Infant Mortality, American 
Journal of Syphilis, vol. iii, no. 1, Jan., 1919, p. 115, quotes Judd, American 
Journal of Medical Sciences, cli, 1916, p. 836. 

14 Commisky, L. J. J., A Preliminary Report of the Routine Wassermann Re- 
action in Hospital Obstetrics, American Journal of Medical Sciences, 1916, 
p. 676, quoted by Vedder, p. 83. 

15 Falles and Moore, The Value of the Wassermann Test in Pregnancy, 
Journal of the American Medical Association, vol. lxvii, 1916, p. 574, quoted 
by Vedder, p. 83. 

16 Vedder, op. cit., p. 84, quotes Dr. Reuben Ottenberg, Sloane Hospital for 
Women, New York. 

17 Darling, Dublin Journal of Medical Sciences, third series, no. 549, Sept., 
1917, p. 147, quoted by Vedder, p. 45. 

is Calmette, Breton et Couveur, Application pratique de la Reaction de 
Wassermann •diagnosis de la Syphilis chez les Nouveau-nes. Comptes rendus des 
seances et memoires de la Societe de Biologie, 1, 1911, 238, quoted by Vedder, 
p. 39. 

19 Vedder, op. cit., p. 85, quotes Dr. Lawson and Columbia Hospital for 
Women, Washington, D. C. 

20 Holbrook, Syphilis in the East Louisiana Hospital for the Insane, Ameri- 
can Journal of Insanity, lxxiii, 1916, p. 261, quoted by Vedder, p. 52. 

21 Newcomer, H. S. et al., One Aspect of Syphilis as a Community Problem, 
American Journal Medical Sciences, vol. 158, Aug., 1919, p. 141, quotes Orton, 
Pennsylvania Hospital for Insane, Philadelphia. 

22 Commission to Investigate the Extent of Feeble-mindedness, Epilepsy, and 
Insanity and Other Conditions of Mental Defect in Michigan (1915). 



208 



SYPHILIS OF THE INNOCENT 

Table 37 — Continued 



Clinic 


Group 


Indi- 
viduals 


Positive] 

Wassermann 
Reaction 




No. 


P.C. 


Michigan State Hospital, Michigan 23 


Insane Women 


606 


77 


12.7 


Warren State Hospital, Pennsylvania 24 


Insane Women 






18.5 


Dr. Collie, London 2 * 


Apparently healthy workmen 


491 


46 


9.36 


St. Luke's Hospital, San Francisco 28 


Female Adult Admissions to 
Hospitals and Dispensaries for 
Medical and Surgical Condi- 
tions 


223 


10 


4.4 


London Hospital, London 27 


Female Adult Admissions to 
Hospitals and Dispensaries for 
Medical and Surgical Condi- 
tions 


389 


20 


5.1 


Infirmary, England 28 


Female Adult Admissions to 
Hospitals and Dispensaries for 
Medical and Surgical Condi- 
ditions 


288 


40 


17.5 


Bellevue Hospital, New York 2 * 


Female Adult Admissions to 
Hospitals and Dispensaries for 
Medical and Surgical Con- 
ditions 


1752 


475 


27.1 


Post Graduate Hospital, New York" 


Female Adult Admissions to 
Hospitals and Dispensaries for 
Medical and Surgical Con- 
ditions 


746 


205 


27.4 


Health Department of New York ^ l 


Criminals 


3809 


1353 


35.5 


Reformatory for Women 32 


Criminals 


864 


349 


40.1 


Prostitutes, Germany 33 


Prostitutes 


260 


102 


39.2 



23 Influence of Syphilis Upon Insanity and Marriage. Note and Comment in 
Social Hygiene, 1915, i, 485. From the Report of the Commission to Investigate 
the Extent of Feeble-mindedness, Epilepsy and Insanity and Other Conditions 
of Mental Defectiveness in Michigan, quoted by Vedder, p. 52. 

24 Mitchell, General Paralysis of the Insane, New Yor~k Medical Journal, vol. 
100, 1914, p. 605, quoted by Vedder, p. 51. 

25 Final Report of the Commissioners, Royal Commission on Venereal Diseases 
quotes Sir John Collie, p. 16. 

26 Knapp, The Wassermann Reaction in Four Hundred Cases Investigated by 
Group Studv Methods, American Journal of Syphilis, vol. 1, 1917, p. 772, quoted by 
Vedder, p/62. 

27 Final Report of the Commissioners, Royal Commission on Venereal Diseases, 
London, 1916, p. 16. 

28 Assinder, Syphilis in the Poorer Classes : Its Diagnosis by the Wassermann 
Test and Its Incidence as Demonstrated Thereby, Birmingham Medical Revieiu, 
vol. lxxvi, 1914, p. 137, quoted by Vedder, p. 44. 

29 Vedder, op. cit., p. 55, gives statistics from Bellevue Hospital, New York, 
compiled by Miss Sarah Greenspan. 

30 Vedder, op. cit., p. 57, quotes F. C. Costen, Post Graduate Hospital of New- 
York, 1916. 

31 Pollitzer, Syphilis in Relation to Some Social Problems, American Journal 
of Obstetrics, vol. lxxiii, 1916, p. 857, quoted by Vedder, p. 71. 

32 Hinton, loc. cit. 

33 Hecht, Die Serodiagnose in Rahmen der Prostituierten-Kontrolle, Deutscher 
medizinische Wochensclirift, vol. xxxvi, 1916, p. 317, quoted by Vedder, p. 48. 



THE COMMUNITY 

Table 37 — Continued 



209 



Clinic 


Group 


Indi- 
viduals 


Positive 

Wassermann 

Reaction 


/ 


No. 


PC. 


Bedford Reformatory for Girls, New 
York" 


Prostitutes 


467 


224 


48.0 


Prostitutes, Baltimore 35 


Prostitutes 


327 


219 


67.0 


Prostitutes, Berlin 38 


Prostitutes 


230 


180 


78.2 


Prostitutes, San Francisco 37 


Prostitutes 


320 


310 


97.0 



34 Kneeland, Commercialized Prostitution m New York, New York, The Cen- 
tury Company, 1913 p. 188, quoted by Vedder, p. 47. 

35 Walker. Symposium on Syphilis, Congress of American Physicians and 
Surgeons, 1916, Journal of the American Medical Association, vol. lxvi, 1916, 
p. 1740, quoted by Vedder, p. 48. 

36 Pinkus, Beitrage zur Kenntnis der Berliner Prostitution ; die Syphilis der 
Prostituierten, Archiv fur Dermatologie und Syphilis, vol. cxiii, 1912, p. 805, 
quoted by Vedder, p. 49. 

37 Ball, Jau Don, and Haywood G. Thomas, A Sociological, Neurological, 
Serological, and Psychiatrical Study of a Group of Prostitutes, American Journal 
of Insanity, April, 1918. 

Expense of Late Syphilis. — It is clear that we can say 
very little about prevalence except as regards certain groups. 
Any estimates of the real cost of syphilis must necessarily be 
somewhat fragmentary. There are, however, some interest- 
ing studies which give some indication of the cost. In 1917 
Dr. Williams 1 made a study of late syphilis as a cause of 
economic disturbance. He took 100 random cases of men 
who died with syphilitic mental disease at the Boston State 
Hospital. The cost to the Commonwealth of Massachusetts 
in hospital care alone, was $39,312 for 100 men who actually 
spent an aggregate of 126 years or over one year apiece in 
the state institutions at a per capita cost of $6 per week. Dr. 
Williams, basing his estimate on the average admission rate 
to Massachusetts hospitals, concluded by showing that there 
were 1500 men and women in Massachusetts who in the course 
of the next five years, would be committed to state hospitals 
because of syphilitic mental disease. 

l Williams, F. E., Relation of Alcohol and Syphilis to Mental Hygiene, 
American Journal of Public Health, vol. 6, 1916, p. 1277. 



210 SYPHILIS OF THE INNOCENT 

Dr. Pollock 1 estimated the economic loss to the state of 
New York on account of syphilitic mental disease for one 
year. He found the total patient population with syphilitic 
mental disease under treatment in institutions during the 
fiscal year of 1917 to be 1554, the per capita cost of support of 
patients in these hospitals being $303.68 a year. The total 
cost of maintenance for this group of patients during one year 
was estimated at $471,918.72. 

A report of the California State Board of Health for 1919 
may be quoted in this connection: "For the past two years the 
state of California has tested all admissions to insane hospi- 
tals. Fourteen and five tenths per cent showed positive evi- 
dence of syphilis, 8 per cent were paretics. On the basis of 
8 per cent it was found to cost the state of California 
$160,000 yearly to support the syphilitic insane.' ' 

Similarly the Eoyal Commission on Venereal Diseases in 
England 2 estimated that England and Wales spent 90,000 
pounds per year on the committed insane suffering from gen- 
eral paresis plus 60,000 pounds for other forms of mental dis- 
ease due to syphilis. 

Estimate of Cast of Syphilis in Massachusetts. — We have 
endeavored to arrive at an estimate of the cost of syphilis to 
the public in the Commonwealth of Massachusetts, that is, 
the expense incurred by the citizens of the Commonwealth as 
a result of syphilis. Any such attempt must, of course, be 
very inadequate at the present time as it is quite impossible 
to get complete figures. However, it seemed worth while to 
make a beginning in this direction, such as might indicate not 
only something of the cost but also the lack of information in 
various institutions. It was found, for instance, that many hos- 
pitals treating syphilis have no idea as to the expense incurred 
because of this disease. Many charitable agencies are spend- 
ing considerable unknown sums of money because of the dam- 
age done to various individuals by syphilis. Our experience 

i Pollock, Horatio, The Economic Loss to the State of New York on Account 
of Syphilitic Mental Diseases during the Fiscal Year Ending June 30, 1917, 
Mental Hygiene, vol. ii, no. 2, April, 1918, p. 278. 

2 Royal Commission on Venereal Diseases, op. eit., p. 34. 



THE COMMUNITY 211 

in the not distant past has been that many of these societies 
were unwilling to give money for the treatment of syphilis 
or the prevention of syphilis, whereas they stood the expense 
of supporting the families which had been damaged or left 
destitute because of syphilis. It seems likely that with a pre- 
sentation of some actual cost figures, a different attitude 
might be engendered. The following data explain the result 
of our attempt to get information on this subject. Consider- 
ing the actual cost of the problem to the State Department of 
Health, and the Boston City Department of Health, the cost of 
committing syphilitic insane patients, that of the care and 
treatment of syphilitic patients at the State Infirmary, at the 
City Hospital for Chronic Diseases, and at three Boston Hos- 
pitals, a figure of practically a quarter of a million dollars per 
year was reached. This quarter of a million represents only a 
very small fraction of the total cost. It does not take into con- 
sideration the care of patients in private institutions or public 
hospitals outside of the metropolitan district of the state, only 
a small number of which hospitals are included. The greater 
part of this money is expended for the care of the patients 
after they are beyond the condition where assistance might 
be offered them through treatment. In other words, less than 
10 per cent of the total amount ($225,000) is expended for 
prevention and treatment, while 90 per cent is used for the 
maintenance of patients who have passed the stage in which 
help is available. 

The following table is a resume of our estimate of the yearly 
cost as borne by the above mentioned institutions and de- 
partments. These estimates were based upon information ob- 
tained as to the number of patients cared for, the per capita 
cost in each case, and the amount of work done by the differ- 
ent departments. The details of this study will be published 
elsewhere. 



212 SYPHILIS OF THE INNOCEXT 

Table 38 

Massachusetts State Department of Health $12067.97 

Massachusetts State Infirmary 41857.28 

Massachusetts State Commission on Mental Diseases 4184.40 

Commitment to Massachusetts State Insane Hospitals 10220.00 

Massachusetts State Insane Hospitals 96732 . 81 

Boston Psychopathic Hospital 14065 . 89 

Boston City Board of Health 6374.56 

City Hospital for Chronic Diseases and Paupers 20721.48 

Massachusetts Homeopathic Hospital 8013.48 

Massachusetts Charitable Eye and Ear Infirmary 1063.96 

Boston Dispensary , 9382 . 02 

$224683.85 

Cost of Syphilis to Private Charities Not Estimated. — In 

addition to the expense defrayed by the taxpayers as actual 
taxes there must be considered all the private endowments to 
take care of various invalids, defectives, and minor indigent 
individuals whose difficulties are directly related to syphilis. 
The work done by various charitable organizations, children's 
societies, and the like, has never been analyzed from the point 
of view of the cost placed upon them as the result of syphilis. 
A solicitation of a number of these societies in Boston has 
shown that they have no idea how much of their expense is to 
be laid to this source. Our experience, however, has indicated 
to us that it is fairly large. These and other expenses of a 
similar type must be considered as direct taxes upon the 
community levied by syphilis and paid by the innocent. 

Cost in Maintenance of Institutions. — One must always 
consider among the items of community expense the part 
played by syphilis in filling our deaf, dumb, blind, and feeble- 
minded institutions. To estimate this in dollars and cents 
we should know the exact percentage of deafness, dumbness, 
blindness, and feeble-mindedness caused by syphilis. These 
figures are not to be secured in America at the present time. 
The examinations of children in schools for the deaf, dumb, 
and blind are not thorough enough to include an exact 
enumeration of the percentage of syphilitics or the relation- 
ship between the existing syphilis and the physical handicap. 
Much has been done to establish percentages for gonorrhea 



THE COMMUNITY 213 

as a cause of blindness. Something should he initiated to 
discover the relationship between syphilis and deafness, 
dumbness, and blindness. 

In 1913 a reliable investigation was made in England by 
Mr. Bishop Harmon 1 who found of 1100 children in London 
Blind Schools 31.2 per cent were certainly and 2.8 per cent 
were probably syphilitic. It is to be noted that in 1904, 18.8 
was the percentage of all blindness which could be attributed 
to syphilis. The increase in percentage in 1913 is partly due 
to the efforts made to prevent ophthalmia neonatorum (gon- 
orrheal infection) as a cause of blindness so that there are 
actually fewer cases of gonorrheal blindness in the schools; 
and partly to the better methods of diagnosing syphilitic eye 
infections. Thus, though one cannot say that syphilitic eye 
infections are actually increasing as these figures might in- 
dicate, yet they are increasing relatively to gonorrhea and 
the interest of the public must be broadened to include syph- 
ilis as a cause of blindness. 

A similar investigation of 845 children suffering from 
acquired deafness in the London County Council Deaf Schools, 
showed that 7.21 per cent were congenital syphilitics. The 
percentage of deafness associated with syphilis was about 
twice as great in girls as in boys. This study indicates what 
might be done in other schools in an attempt to estimate the 
relation between syphilis and deafness, dumbness, and blind- 
ness. 

Cost of Syphilis in Aid to Destitute Families. — Another 
direct loss in addition to the cost of institutions for the diag- 
nosis, treatment, and custodial care of the syphilitic is the 
cost to the community of families made destitute by syphilis 
in some wage-earning member. As indicated in the chapter 
on the family, in the early stages of syphilis temporary aid 
is sometimes necessary in families who can just get along 
with a certain income. If this is cut down by hospitalization 
of the wage-earner, by a considerable loss of time from work 
by out-patient treatment, or by loss of a job through fear of 

l Harmon, op. cit., pp. 30, 152. 



214 SYPHILIS OF THE INNOCENT 

infection of others, or what not, aid must be given either by 
public or private charity. There are no figures on this as far 
as known. 

In the later more incapacitating stages of syphilis perma- 
nent aid must often be given to the patient and to the family. 
Indication of what this means has been given (see page 167, 
Chapter IV). As an example of the cost to the public we 
may again consider the Eossini family already cited on page 
136, Chapter IV. As a result of syphilitic mental disease the 
father was committed to a state hospital. The mother who 
also had syphilitic disease of the central nervous system 
received treatment, the expense of which was defrayed by 
the state. Her condition required a certain amount of hos- 
pitalization from time to time. The oldest son was sent to 
an industrial school. The two youngest children were con- 
genital syphilitics and had to be cared for in a school for the 
feeble-minded. Four other children were left at home and a 
large part of the expense of their care fell upon the state. 
The oldest of these children at home was syphilitic and 
required treatment. It is probable that the mother will be 
permanently incapacitated in which contingency the entire 
care of the children will fall upon the state or private charities. 

Indirect Financial Loss — Diminished Earning Capacity and 
Productivity. — In addition there is what might be termed an 
indirect financial loss represented by a diminution of existing 
productive power due to a gradual or sudden decline in earn- 
ing capacity. Temporary or permanent absence from work is 
only too often seen in late syphilis, and even in the beginning 
of the disease this loss of productivity is at times quite strik- 
ing. For the best protection of the individual and the com- 
munity, a patient acquiring syphilis should be hospitalized 
for a period at the beginning of his disorder. This means 
time off and lessened productivity. Patterson, 1 in a study of 
three Chicago hospitals for 1912 to 1913, found that the 
average time out of work because of syphilis was three weeks 
for each patient. The following figures present this point: 

l Patterson, J., An Economic View of Venereal Infections, Journal of the 
American Medical Association, vol. lxii, no. 9, Feb. 28, 1914, p. 670. 



THE COMMUNITY 

Number op Cases 

Michael Reese Hospital 107 

Wesley Hospital 52 

Cook County Hospital 917 

Total 1076 



215 



Days Lost 
1562 
593 
19389 



21544 



Loss of time through hospitalization in the early or late 
stages of syphilis was shown in a grim manner during the 
late war. While syphilitic s were hospitalized and kept out 
of action their places at the front were filled by other men. 
It was reported that this became such a serious matter in 
the Austrian army where men consciously attempted to 
acquire venereal disease that they might be hospitalized and 
removed from the front that a rule was made that any man 
acquiring venereal disease would be sent to the front line 
trenches. What the actual loss may mean to military forces 
is showm in the accompanying figures from the British navy. 1 
For the year 1912, with an average strength of 119,540 men, 
there was a loss of 107,145 days because of syphilis. This 
was without very adequate hospitalization such as would be 
prescribed today. 



Year 1912 — Average Strength, 119,540 





Number 

OF 

Cases 


Total 
Number 
of Days 

Lost 


Average 
Number 

Sick 
Daily 


Ratio per 1,000 




Cases 


Sick daily 


Syphilis I 


715 


15,439 


42.18 


5.98 


.35 


Syphilis II 


2744 


91,706 


250.56 


22.95 


2.09 






107,145 









American figures on the average number of soldiers of each 
one thousand incapacitated each day follow: 

Noneffective Rates per 1000 for Syphilis 2 

Year White Colored 

1917 -. 0.86 2.63 

1918 0.96 2.52 

1919 1.18 3.80 

1 Royal Commission on Venereal Diseases, Report of the Commission, London, 
1916, p. 90. 

2 From the War Department, Office of the Surgeon General. 



216 SYPHILIS OF THE INNOCENT 

In spite of the loss of time, the hospitalization of syphilitics 
is urged in the early stages of the disease when the person is 
most contagious and a community menace. It is more eco- 
nomical in the long run as it offers means for intensive 
treatment and proper training of individuals as to prophy- 
laxis. The more beds a community can provide for early 
cases the better the treatment and the smaller chance of later 
incapacitating syphilitic diseases which in their turn require 
intramural hospital care. Tarnowsky 1 tells of an unrestricted 
syphilitic woman who contaminated 300 men in ten months. 
One cannot even compute the effects of this on the innocent 
members of their families and the community. 

An obvious difficulty in hospitalization is the unwillingness 
of the patient to give up work. Experience at the Massachu- 
setts General Hospital 2 indicates that most jobs do not have 
to be given up. Employers are more willing to make adjust- 
ments for a patient sick enough to be in bed than for one 
who must take time off to report to an out-patient department. 
After hospital care they take more kindly to the idea of out- 
patient treatment. In the period of out-patient care the 
amount of time taken out of working hours may be diminished 
by night clinics. These are to be urged particularly for non- 
hospitalized contagious cases, neglect of whose treatment for 
one reason or another directly affects the community. 

Pollock 3 in his computation of the economic loss on account 
of syphilitic mental diseases for the state of New York during 
1917 showed that the loss in earnings alone was almost 
$5,000,000. 

Williams 4 in his study of 100 cases of syphilitic mental 
disease shows the financial loss based on what the patients 
would have earned if they had lived out their normal span of 
life. The earning power of ten was known and this multiplied 
by the average expectation of life as estimated by the life 
insurance companies showed a financial loss of $212,248 for 
the group of ten. 

i Bulkley, op. cit., p. 204 quotes Tarnowsky, N. Y. Medical Record, March 9, 
1889, p. 279. 

2 Report of the Massachusetts General Hospital, 1918-19, p. 27. 

3 Pollock, op. cit., p. 279. 

4 Williams, loe. cit. 



THE COMMUNITY 217 

It is evident that the indirect loss of productive power 
materially increases the cost of syphilis to society. Of the 100 
men investigated by Williams, 78 were married and left 
dependent wives and children. One cannot definitely assume 
that the financial problem of these families will be as typical 
of the families of all committed late syphilitics who die in a 
hospital. It is indicated, however, in our study of 41 com- 
mitted paretics (see page 167, Chapter IV), 65 per cent of 
whose families received permanent financial aid. 

Community Effects of Actions of Paretics. — In studying the 
effect of the late stages of syphilis on the community one must 
take cognizance of the disordered judgment of the paretic 
patient and his acts. Paretics are occasionally responsible 
for minor financial losses to the community, such as the 
failure of public institutions through their bad business 
ventures. One can only wonder how many financial fiascos, 
how many inflated concerns floated on the market, are the 
creations of the general paretic in one of his grandiose moods. 

Dr. Mercier 1 has pointed out some of the medico-legal as- 
pects of general paresis. Instability of mind may result in 
sudden violent outbreaks such as a fight on the street or un- 
warranted anger at the disobedience of a child. The exalted 
type has no idea of property or values, and will purchase be- 
yond his means, make contracts he cannot fulfill, and enter into 
speculations. The increased sexuality of the patient may lead 
to immorality and the divorce court. The validity of a will 
may be questioned. By early recognition of the disease and 
care for the patient, expense to the family and the community 
may be prevented in reducing the cases brought before : 

(1) the Criminal Court (stealing) 

(2) the Property Court (litigation about validity of will) 

(3) the Divorce. Court (immorality due to increased sexu- 

ality) 

(4) the Equity Court (speculations, breaking contracts). 

i Mercier, C, Clinical Aspect of General Paresis. (System of Syphilis, 1914, 
vol. iii), sec. ed., London, Frowde, Hodder and Stoughton, p. 81. 



218 SYPHILIS OF THE INNOCENT 

Social Losses — Decreased Marriage Rate. Another of the 
more important community losses is the lessened marriage 
rate. Many syphilitics, aware of their disease and its probable 
consequences, do not care to contract marriage. In others 
the unfortunate results of syphilis occur early in life before 
marriage is feasible. 

Reduced Number of Children. — An even greater loss is the 
reduced number of children in the families of married syphi- 
litics. We have shown in the family statistics the enormous 
human wastage in accidents to pregnancies. Syphilis is a 
destroyer of potential man power. In these post-war days 
anything which increases infant mortality is of extreme 
moment, especially abroad where the birth-rate for the last 
years has been dangerously low and the death-rate due to the 
loss of male adults in the prime of life has been extraordinarily 
high. Superimpose on this the additional toll of abortions, 
miscarriages, stillbirths, polymortality of infants, and sterile 
marriages, due to the increased amount of syphilis as a result 
of war, and one has a large problem. In Germany 1 the spread 
of venereal diseases has been so great that contagious cases 
abound everywhere. There are not enough hospitals in which 
to keep them. The effect on the families and the next genera- 
tion can be conjectured. It is estimated that in France^ 
army 2 so many men of the procreative age are syphilitic that 
for each syphilitic infection France is deprived of one soldier 
and one mother of a family during the period of 1936-1945. 
That the ex-soldiers all over the world are not going to take 
the necessary precautions or receive enough treatment to en- 
able them to have healthy children is to be feared. Dr. Ehys 3 
declares that in two English brigades in which every facility 
for treatment was provided, no one availed himself of the 
privilege. If men took no trouble while away from home 

1 Nederlandsch Tijdschrift quotes the Medisinische KliniJc of Berlin (Ameri- 
can Medical Association, December, 1919). 

2 Thibierge, G., Syphilis and the Army, London, University of London Press, 
Ltd., 1918, p. 32. 

3 Rhys, O., Analysis of 1500 Cases of Venereal Diseases, All Male, at the King 
Edward VII Hospital-Clinic at Cardiff, Wales, Social Hygiene Bulletin, vol. vii, 
no. 1, Jan., 1921. 



THE COMMUNITY 219 

they are not likely to visit disinfecting stations near home. 
Hence their wives and children will suffer. 

Collins 1 rightly advises that a list of syphilitic ex-service 
men he obtained from Washington and an attempt made to 
get these former soldiers to report to the Public Health 
Service for examination and further treatment if indicated. 

Syphilis and Divorce. — Syphilis is rarely the sole cause of 
divorce. AVhen acquired early or late after marriage it may 
be a cause of separation or divorce but it is usually associated 
with other social difficulties such as alcoholism, cruelty, non- 
support, and it is, of course, prima facie evidence of adultery. 
The disclosure after marriage that syphilis has been acquired 
before marriage rarely disrupts the home. A possible reason 
is that the discovery is often made after a considerable period 
of satisfactory marital relations. An indication of the com- 
parative infrequency of divorce among syphilitics is shown 
by statistics of 515 married paretics admitted to the Psycho- 
pathic Hospital. Only 2.3 per cent were divorced. 

Standards of Living Lowered. — General standards of liv- 
ing are lowered by syphilis through its power to affect the 
finances of a family. The families who drop below the line 
of self-support because of late syphilis in any member, 
increase the group who cannot keep to an adequate standard 
of life and happiness. 

Loss of Life Through Inefficiency of Neurosyphilitics. — 

There is a certain definite yearly loss of life through the 
inefficiency of neurosyphilitics who, although mentally or 
physically incapacitated, still hold responsible positions. 
Many paretics are locomotive engineers or chauffeurs and if 
no trouble results from sudden attacks of confusion it is 
largely due to pure luck. At a conference 2 in January, 1920, 
of officials of the United States Public Health Service, United 
States Railroad Administration, and the American Social 

1 Collins. H. G., Syphilis hi the Innocent, Journal of the Kansas Medical 
Society, vol. 21, no. 7, Jan., 1921. 

2 Social Hygiene Bulletin, vol. 7, no. 2, Feb., 1920, p. 4. 



220 SYPHILIS OF THE INNOCENT 

Hygiene Association, it was demonstrated that there was a 
definite relationship between venereal disease and impaired 
efficiency, accidents, and casualty costs. Several examples 
were cited showing that men in both the early and advanced 
stages of paresis were frequently found in charge of trains or 
in other positions endangering the lives of the public. 

Stokes 1 has made a rather intensive analysis of the situa- 
tion as regards railroad employees. In collaboration with 
Brehmer he writes that the investigation was undertaken 
because of the "impression that syphilis is an exceptionally 
common disease among railroad employees and that it con- 
stitutes a grave and unrecognized menace to their personal 
welfare and industrial efficiency, and to the safety of the 
traveling public. It impairs efficiency and brings discredit on 
railroad administration." In a survey of 50 syphilitic rail- 
road employees they found that three fourths were engaged 
in the operation of trains, one third being on the engines. 
Nearly one half of the cases were not diagnosed prior to 
coming to the clinic although a high percentage showed gross 
neurological findings and mental symptoms. Of the men 
examined, practically 80 per cent had syphilis of the nervous 
system. Definite mental symptoms were determined in nearly 
40 per cent. They conclude that the routine railroad medical 
examination is insufficient to protect the public and make 
three suggestions to correct this : 

1. Routine Wassermann on all employees 17-25 repeated when age 

of 32. (By 32nd year 91 per cent were infected.) (By 
25th year 60 per cent were infected.) 

2. Effective annual examination of men 25 to 40 rather than men 

over 50. More attention to neurological examination. (71 
per cent of late symptoms occur 6 to 20 years after infection, 
hence should examine neurologically men 23 to 45.) 

3. Educational propaganda by railroad medical departments for 

employees and medical staff to show importance of syphilis 
in industrial efficiency and hygiene. 

Case 140. Stokes 1 reports a case of a locomotive engineer 36 years 
of age who was suffering from tabo-paresis. He had been treated at 

l Stokes, J. H. and H. E. Brehmer, Syphilis in Eailroad Employees, Journal 
of Industrial Hygiene, yol. 1, no. 9, Jan., 1920, p. 420. 



THE COMMUNITY 221 

the clinic for a year and a half and had a remission of six months ' 
duration, during which time he carried his usual run. He suddenly 
appeared at the clinic having been sentenced for 90 days because of 
his share in a freight-passenger wreck. He had had a lapse of 
memory and passed a siding where he was to meet another train. 
The railroad had not tried to find out if there was a medical factor 
responsible for his share in the wreck. 

Case 141. Joseph Griffin, a man of 50 years, was a railroad con- 
ductor. He had been in the employ of the company for 33 years. 
His position was a responsible one, as it is the conductor who gives 
the train orders. While on duty he had an attack and became uncon- 
scious in the baggage car. When the train reached its destination he 
was found in a state of coma which lasted for several days. His 
diagnosis was general paresis. It was mere good luck that on this 
particular trip he was not needed at the time the attack occurred. 

A study of occupations of 755 paretics who have been 
patients at the Psychopathic Hospital showed that 61, or 8.07 
per cent held positions involving the lives of others. The 
number in each type of occupation was as follows: 

Engineers 11 Boat Captain 1 

Brakemen 4 Sailors 6 

Trainman 1 Life-guard 1 

Switchman 1 "Lighthouse Co. 77 1 

Conductors 4 Policemen 3 

Motormen 4 Firemen 5 

Yardmaster 1 Chauffeurs 12 

Stationary Engineers 2 Coachmen 2 

Naval Officers 2 

Engineers and chauffeurs seem to be the most frequent 
occupations, although conductors, motormen, and brakemen 
are not far behind. We must, then, look to our transporta- 
tion systems, — railroads, electric cars, ships, automobiles — 
for our ' ' dangerous paretics. ? ' More careful medical examina- 
tions and licensing are indicated as preventive measures. 

Syphilis and Industry. — Oliver 1 brings out the importance 
of syphilis in industry. He takes up industrial inefficiency 

l Oliver, E. A., Syphilis, An Inestimable Factor in Industrial Inefficiency, 
Journal of Industrial Hygiene, vol. 1, no. 5, Sept., 1919, p. 247. 



222 SYPHILIS OF THE INNOCENT 

from the point of view of the employer rather than of the 
employee or family. He points out the danger of employing 
syphilitic people in the following cases : 

Case 142. (Oliver's case 1) had sustained an injury while working 
at his job. A box fell on his back. Earlier in his life he had 
had a fractured spine. He recovered and returned to work, where 
he was a satisfactory employee for several years. Then he began to 
have pains in his back and legs and was sure that these pains were 
caused by his previous injury. He was found to be a tabetic and 
improved markedly under treatment at the industrial clinic. 

Case 143. (Oliver's case 2) was a foreman who became markedly 
inefficient. He had had several attacks of Unconsciousness and from 
an energetic foreman became a careless and absent-minded workman. 
He was found to have nervous system syphilis, and under treatment 
the standard of his work has been raised. 

Case 144. (Oliver's case 3) scratched the back of her hand with 
a piece of wire while working in a millinery department. After local 
treatment for a few weeks the trouble disappeared. The girl was 
found to be a congenital syphilitic and improved under treatment. 
However, she was away from work off and on for two years before 
she was well enough to be an efficient employee. This was a rather 
expensive case for the industry. 

Oliver advises that all employees and all applicants "be 
given a Wassermann test. He does not believe that those 
with a positive Wassermann should be discharged or not 
employed hut rather that they should be treated. He advises 
pay clinics for all industrial centers so that the men who 
cannot afford to pay private fees can have efficient treat- 
ment. He also recommends the discovery of the source of 
infection and all contacts as a public-health attitude for 

industry. A less advanced point of view is that of the 

shipping firm which refused to employ William Carter, 
who had a luetic hemiplegia, on the ground that they never 
employed persons with a known positive Wassermann reac- 
tion. The fact that the patient had a nervous system involve- 
ment might well be a reason for refusing to risk future in- 
capacitation, but employment was refused entirely because 
of the serum reaction. 



THE COMMUNITY 223 

Syphilis and Industrial Compensation. — Syphilis often acts 
as a factor in the prolongation of convalescence of various 
diseases and thus puts upon industry a burden of expense in 
the form of compensation. Frequently insurance companies 
suffer considerable financial loss through the increased incre- 
ment of expense due to this prolongation of convalescence. 

Everett 1 has called attention to this matter and gives 
the following illustrations: 

Case 145. (Everett's case 1) sprained his ankle. Ordinary recov- 
ery would have taken place in 4 to 6 weeks, at a compensation of 
$72.15. Owing to a latent syphilis which was stirred up, complica- 
tions arose and the compensation was $336 for seven months. 

Case 146. (Everett's case 2) sustained a fracture of the thigh 
bone. After a year's compensation or $260 plus two weeks' medical 
service, the company would ordinarily have been able to stop payments 
as the injury would have healed. But owing to syphilitic complica- 
tions, the thigh had not healed, the chances were against the man's 
ever returning to work, and the insurance company would probably 
have to continue payments indefinitely. 

Mistakes in Attitude Towards Syphilis — Moralistic Point 
of View. — The entire question of the contagiousness of syph- 
ilis and public welfare as well as the financial and social losses 
caused by syphilis is, in the last analysis, bound up with the 
general attitude of the public towards the disease. A glance 
at the negative side brings to light the most frequent mistakes 
in the usual approach to syphilis. The moral attitude, the 
feeling that all syphilitics are renegades, does a tremendous 
amount of harm. It pays no heed to the large number of 
innocent syphilitics whom we have been studying, it brands 
the man who has transgressed once in early youth together 
with the habitual roue. It makes no distinctions, it sweeps 
all syphilitics into the group of outcasts. True, many God- 
fearing persons have been rigid moralists and have felt that 
they w^ere aiding in stamping out venereal diseases. But no 
real progress will ever be made until syphilis is freed of the 
idea of moral taint and just punishment for sin, and is put 

l Everett, E. H., The Cost of Venereal Disease to Industry, Journal of In- 
dustrial Hygiene, vol. ii, no. 5, Sept., 1920, pp. 178-181. 



224 SYPHILIS OF THE INNOCENT 

on a plane with other diseases. The church can probably aid 
in this as mnch as any other organization. Doctors, lawyers, 
teachers, social workers, all must do their share. 

False Idea of Fear as Deterrent to Sex Appetite. — Unfor- 
tunately, the old idea that fear of consequences will curb 
the sex appetite and so avoid syphilitic infection has not 
proved true. Year after year medical students and others 
who know all that may happen to them, appear at the clinics 
for treatment. The value of propaganda for knowledge is 
not so much that individuals may remain continent outside 
of marriage but that men may do what they do with their eyes 
open, so that the innocent may be protected by proper pre- 
ventive and post-infection measures. 

Case 147. James Foster, who had had adequate treatment for his 
syphilis, proved his cure by acquiring a new syphilitic infection. 
While under treatment he said, "Doctor, I have sure learned my 
lesson this time. ' ' On being asked what he meant, he replied : ■ ' When 
I am cured again I am going to use precautions!' 7 

It seems well to emphasize here the difference between prop- 
aganda for the dissemination of knowledge and the duty one 
owes to the patient as an individual. While all are definitely 
agreed upon the value of education to the end that the public 
will come to recognize venereal diseases as infectious diseases 
that should be cared for as are other contagious and infectious 
conditions, yet the individual must never be lost from sight. 
He has certain rights that are just as inviolate as those of 
any other patient who seeks medical advice. For propaganda 
purposes one should not hold up any given individual as an 
example or do anything that would lead to his definite dis- 
comfort. As long as the individual is not in a contagious 
state, it is not logical nor reasonable to expose him to the 
difficulties that would arise if various members of the com- 
munity knew of his condition. While one must work for the 
time when it will be possible to speak of syphilis as an afflic- 
tion unconnected with the thought of shame, until such a time 
arrives, one must do all one can to protect the individual if 
he is in no sense a community menace. 



THE COMMUNITY 225 

Over or Under Emphasis on Syphilis. — There is always the 
danger of taking syphilis too seriously or not seriously 
enough. There are persons who smile at the possibility of 
acquiring syphilis, who shrug their shoulders when they have 
acquired it, scoff at the idea of prolonged treatment, and are 
incredulous years later when told that syphilis is causing all 
their recent difficulties. Others live in terror of acquiring 
syphilis, shudder for the future when they are syphilitic, and 
are skeptical of a promised cure with faithful treatment. 
These extremes of mental carelessness and caution apply 
equally to a consideration of syphilis acquired by intercourse 
or chance contact. Sanity and balance must be maintained 
and a rational public attitude established. Syphilis is prob- 
ably not an incurable disease if treated early and adequately. 
Treatment somewhat later will hold the disease in check. 
Treatment many years after infection when some damage 
has been done may give a remission and prevent future illness. 
Syphilis is a serious disease but not a hopeless one. 

All Syphilitics Not Contagious. — Allied with the above is 
the idea that all cases of syphilis are always contagious. If 
this were true few would escape, as all meet syphilitics in 
daily life at one time or another. Stokes 1 gives a rather 
amusing picture of fearful persons : 

I have known eminent medical gentlemen to wash their hands with 
almost hysterical eagerness after touching my door knob, or after 
the presentation of one of my cases in a clinic ; and nurses and office 
assistants joining my stair* to be the recipients of condolences from 
friends and tearful protests from relatives; the supposedly well- 
informed heads of training schools to refuse me nurses when, without 
their realizing it, I had identified for them repeatedly the dangerously 
contagious syphilis which they were unconsciously nursing in their 
wards and in their finest private rooms. Of the uninformed, we, of 
course, expect such blunders. That similar types of thinking are 
still prevalent among the flower of the profession is only a tribute 
to the super-darkness that surrounds us. 

l Stokes, J. H., To-day's World Problem in Disease Prevention, Washington, 
U. S. Public Health Service, Treasury Department, p. 106. 



226 SYPHILIS OF THE INNOCENT 

Early untreated syphilis is contagious under the conditions 
already mentioned. Late syphilitics are practically never 
contagious. Although syphilitic babies are most contagious, 
late congenital syphilitics are not. Thus, great care must be 
taken in the placing out of syphilitic babies so that other chil- 
dren shall not be infected. All children offered for adoption 
should be pronounced syphilis-free by a competent doctor. 
As a symptom-free congenital syphilitic child of school age 
is quite safe from the point of view of contagiousness he 
can go to school, be placed out in a family, and play with 
children. However, it is wisest for a family not to adopt 
legally such a latent syphilitic child even though noncon- 
tagious, as he is likely to have later incapacitating diseases. 
The burden of care of such children should rest with the state. 

Case 148. The case of the Guardino 1 baby typifies the dangers 
oftentimes run in the poorer families. Since its birth the mother had 
boarded her 6 months old illegitimate baby with a woman who had no 
permit for keeping children. Then desiring to get rid of it perma- 
nently, the mother left it with a neighbor , telling her to bring it to 
the hospital, as she was leaving town. The neighbor, a pregnant 
woman with three children, brought the baby to the clinic, realizing 
that it was sick and undernourished. The child was obviously a con- 
genital syphilitic and was covered with an actively contagious syphil- 
itic rash. As luck would have it, no one of the two families with 
whom the baby had lived was infected. The baby was given syphil- 
itic treatment in a hospital and the mother was prevented from 
abandoning it. 

Case 149. Mr. and Mrs. McCarthy 1 brought a 6 weeks old baby 
to the hospital because of a rash. This was not their own child but 
had been taken for adoption two weeks previously. They had 
received the child from an infant asylum and it had been perfectly 
well. The "home" had received the baby two days before. No 
questions had been asked of the woman who brought it, and it had 
been placed out without examination merely because it appeared well. 
A few days later a skin rash and a cold developed. As the baby did 
not improve in two weeks the foster parents thought it wise to bring 
it to the hospital. The child had a syphilitic rash, snuffles, desquama- 
tion, and exudate in the corners of the mouth. It was in a highly 

l Children's Hospital, Boston. 



THE COMMUNITY 227 

contagious state. Inquiries showed that there were two children liv- 
ing in the McCarthy family at this time, one of whom was only four 
years old. Luckily the foster mother and her sister had cared for 
the child, not allowing the child to touch it, as they thought its 
"cold" might be catching. Neither one of them had kissed the child 
on the mouth and had no abrasion so far as known. The baby was 
returned to the asylum and was placed in a hospital where it was not 
expected to live. This case is an indictment against placing out 
agencies which do not thoroughly examine all children in their care. 

Case 150} Massachusetts General Hospital case. A young delin- 
quent girl with a contagious case of syphilis was treated until all 
danger of contagion was over. A plan was then made whereby the 
child was to change her home environment and to live with a relative 
in another part of the city. In this home there was a child of 10. 
Before the hospital worker could make arrangements with the rela- 
tive, the probation officer had gone to the woman and told her that 
the girl had syphilis and that she should not be allowed to live in the 
family lest the little girl should become infected. 

All efforts of the medical social worker to show the relative that 
her own child was not in any danger were of no avail and the girl 
remained under the same bad home influence as before. As a result 
she ran away again, and when next arrested was sent to prison, If it 
had not been for the misinterpretation of the medical situation this 
girl might have been saved. 

Case 151. Samuel Cohen became a state ward at the age of 9. 
Although he was not contagious, he was a congenital syphilitic. Hence 
he was placed out but never adopted. 

Case 152. The 5 and 6 year old boys of Agnes Mazzarello were 
under treatment at the clinic, one having a positive Wassermann 
reaction and the other specific condylomata. They were found to 
need a vacation, but the agency made no attempt to place them on 
account of the contagiousness of the second child. The proper tech- 
nic was used, the children were treated, examined again when there 
were no longer any specific lesions, and were then sent away for their 
vacation. A short time after this the mother died of influenza and 
an examination was made again with the idea of placing them out 
permanently. 

l Lewis, O. M., Medical Social Service as a Factor in Protective Work, 
National Conference of Social Work, New Orleans, April, 1920, p. 313. 



228 SYPHILIS OF THE INNOCENT 

Mistakes in Interpretation of Stigmata or Symptoms. — The 

layman who knows a few of the common stigmata of syphilis 
is only too apt to confnse them with similar non-syphilitic 
difficulties. All skin lesions are not syphilitic. Most youths 
with rashes on their faces are not suffering from syphilis 
but from acne. Syphilitic skin lesions are almost always on 
the trunk and not on the exposed part of the body. Many 
people think rachitic children or those with decayed teeth are 
syphilitic. It is an injustice for a layman to make a diagnosis 
on such evidence. Late congenital symptoms are often con- 
sidered as acquired and a juvenile general paretic branded 
as having acquired syphilis. 

Ignorance of Syphilis as Family Disease. — Another com- 
mon error is forgetting that the families of syphilitics are 
potential syphilitics. Even after realization, many people 
hesitate to take active steps towards examining the family 
for fear of causing marital discord. This subject has been 
covered under examination of the family. 

Over-Emphasis of Possible Causal Relation With Social 
Difficulties. — Workers with syphilitics must not take the dis- 
ease so seriously as to find a causal relation between all the 
social problems of syphilitics and the disease itself. Syphilis 
may cause certain social abnormalities and merely be coinci- 
dent with others. 

Remedial Measures Against Infection. — The popular mis- 
takes in regard to syphilis, above noted, should gradually dis- 
appear as the remedial measures against infection become 
more stabilized. In a study of innocent syphilis one must first 
consider the direct measures, both those which will minimize 
the possibility of acquiring innocent genital syphilis and those 
which diminish the likelihood of acquiring innocent extragen- 
ital syphilis. 

Legal Approach to Eradication of Innocent Genital and 
Extragenital Syphilis. — The direct measures towards the 
eradication of innocent genital syphilis are mostly legal and 



THE COMMUNITY 229 

have already been discussed in the chapter on the family. The 
physician may be released from the bonds of professional 
confidence, so that he may prevent the marriage of a con- 
tagious syphilitic; health certificates may be insisted on for 
all applicants for a marriage license; marriages may be 
annulled when syphilis is discovered. Outside the power of 
the law in most cases is the insistence on the early examina- 
tion of the members of the families of all syphilitics. Mar- 
riages before the period when most men acquire syphilis 
would cut off a large percentage of marital infections. Unfor- 
tunately such marriages depend so largely on finances that 
one can only hope that the economic situation in the years to 
come may permit young men to marry earlier. 

Again the remedial measures against the spread of innocent 
extragenital infections are mostly legal. Small operations 
such as circumcision and tatooing, must be performed only 
by licensed persons ; midwives must be licensed ; public places 
such as barber shops and soda fountains must be inspected 
by the boards of health, and regulations as to the boiling of 
articles, use of paper cups, etc., must be enforced. Judicious 
publicity about the contagiousness of objects and persons is 
advisable. By this means contagious syphilitics can be urged 
to observe hygienic rules in the home and special attention 
can be called to the care of syphilitic infants. 

Value of General Preventive Measures. — In the long run 
any measures directed towards the eradication of syphilis, 
whether innocently or venereaUy acquired, will tend to 
diminish the amount of innocent syphilis. We will not go into 
detail regarding the many efforts of general prevention but 
will merely refer to a summary of some of the more frequent 
prophylactic measures, including the more direct as well as 
the indirect measures bearing on innocent syphilis. 1 

l See Programme of Medical Education and Law Enforcement Measures 
issued by Treasury Department, United States Public Health Service, chapter 
xvi, Puolic Effort vs. Syphilis, also Dr. J. H. Stokes, The Third Great Plague, 
Washington, D. C, and Social Hygiene Bulletin, Nov., 1919, for further dis- 
cussion and suggestions. 



230 SYPHILIS OF THE INNOCENT 

Table 39 

I. Public Grants for Study and Prevention. 

1. Federal appropriations to state to aid in combating venereal diseases. 

2. Establishment of bureaus of venereal disease by many state boards of 

health and United States Public Health Service. 

3. Appropriations by Interdepartmental Social Hygiene Board to uni- 

versities, schools, for study of venereal disease, and teaching of sex 
hygiene. 
LT. Education Efforts and Publicity. 

1. Lectures ] 

2. Pamphlets, journals, books I For doctors, social workers, teachers, 

3. Posters and placards j> ■ heads of families. By social and mental 

4. Exhibits hygiene associations, boards of health. 

5. Movies 

III. Legal Attack: Laws and Their Enforcement. 

A. General. 

1. Adequate examination before marriage. 

2. Doing away with professional confidence. 

3. Annulment of marriage because of venereal disease. 

4. Enforcement of treatment of all contagious cases in institutions, 

prisons, etc. 

5. Legal follow-up of all untreated contagious cases by boards of health 

through notification laws. 

6. Suppression of quack advertising, practice, etc. 

7. Legalizing personal prophylaxis. 

B. Suppression of Prostitution. 

1. Workable law prohibiting prostitution with provision for probation. 

indeterminate sentence, industrial rehabilitation, etc. 

2. Abolition of segregated districts. 

3. Injunction and abatement laws. 

4. Licensing of amusement places, taxicabs. 

5. Enforcement of penalties against white slavery. 

6. Isolation and treatment of infected prostitutes. 

IV. Efforts for Diagnosis. 

1. Hospitals and dispensaries, sufficient in number and equipment. 

2. Free laboratories for serum tests. 

3. Follow-up family and contacts of syphilitics. 

4. Examination (including routine Wassermann reaction) of all people 

in public institutions of all kinds such as child-caring, deaf, dumb, 
and blind, feeble-minded institutions, hospitals, and prisons. 

5. Examination of employees in industrial establishments, railroads, etc. 

V. Efforts for Treatment. 

1. Treatment of all infected persons in institutions whether contagious 

or not. 

2. Rigid follow-up of all early and late hospital cases for continuous treat- 

ment. 

3. More public out-patient clinics (evening and day) and hospital beds 

for syphilitics. 

4. Standardizing of hospitals. 



THE COMMUNITY 231 

5. Detention hospitals for contagious uncooperative cases. 

6. Free expert treatment and free drugs (state or privately paid) for the 

poor. „ 

7. Pay clinics for persons of moderate means. 

8. Locating source of infection and establishing treatment. 

Infectious, contagious diseases are always matters of im- 
portance to the whole community. The effects of syphilis are 
even more far-reaching than of acute diseases such as typhoid 
fever or smallpox and do not end with the spread of the 
disease. However, the matter of contagiousness is very per- 
tinent. Accidental extragenital infections are by no means 
infrequent and if one numbers among the innocent victims 
the mates and children of the syphilitic, the extent of this 
phase of the problem is quite stupendous, and comes within 
the purview of the public-health departments, municipal, state 
and national. 

But syphilis is of greater interest to society than in its 
aspect of accidental contagiousness. It causes much loss of 
economic efficiency, it disables men and women in their prime, 
it leads to various defects in children, who either die early 
or go through life handicapped. It is a considerable factor 
in race suicide through its part in lessening the marriage rate 
and producing sterility, unsuccessful pregnancies, and infant 
deaths. The apparent cost to the community, great as it is, 
does not give more than a small fraction of the total cost. 

Whether viewed from the standpoint of its effect on the 
individual, his mate, and children, the family group, or of 
the dangers of contagion, the cost to society for medical and 
social care, the loss of economic productivity in industry, the 
difficulties of the mentally deranged, syphilis is always a 
community problem. In all its manifestations the social 
structure is involved. Any problem implicating the community 
at large to such a degree deserves the intelligent attention of 
the members of the community, and per contra the members 
of the community are entitled to a knowledge of a subject of 
such major importance to them individually and collectively. 



232 SYPHILIS OF THE INNOCENT 



REFERENCES 

Blaisdell, J. H., The Menace of Syphilis to the Clean Living Public, Boston 

Medical and Surgical Journal, vol. clxxii, no. 4, April 1, 1915. 
Browning, C. H. and D. Watson, Venereal Diseases; A Practical Handbook for 

Students, with an introduction by Sir John Bland-Sutton, New York, Ox- 
ford University Press, 1919. 
Bulkley, L. D., Syphilis in the Innocent, New York, Bailey and Fairchild, 1898. 
Collins, H. G., Syphilis in the Innocent, Journal of the Kansas Medical Society, 

vol. 21, no. 7, Jan., 1921. 
Department of Medical Social Work, Boston City Hospital Report, Feb. 1, 1919. 
Diday, P., Treatise on Syphilis in Neiv-bom Children and Infants at the Breast, 

translated by D. W T hitley with notes by F. R. Sturgis, New York, Wm. Wood 

and Co., 1883. 
Everett, R. H., The Cost of Venereal Disease to Industry, Journal of Industrial 

Hygiene, vol. ii, no. 5, Sept., 1920. 
Hinton, W. A., Specific Inhibitory Reaction of Cholestrinized Antigens in the 

Wassermann Test, American Journal of Syphilis, vol. v, no. 1, Jan., 1921. 
Jeans, P. C, Syphilis and Its Relation to Infant Mortality, American Journal 

of Syphilis, vol. iii, no. 1, Jan., 1919. 
Lewis, O. M., Medical Social Service as a Factor in Protective Work, National 

Conference of Social Work, New Orleans, April, 1920. 
Lane, J. E., A Few Early Notes on Syphilis in the English Colonies of North 

America, Archives of Dermatology and Syphilis, vol. 2, no. 2, Aug., 1920. 
Mercier, C, Clinical Aspects of General Paresis, System of Syphilis, second 

edition, London, 1914, FVowde, Hodder, and Stoughton, vol. iii. 
Monthly Bulletin of the City of Boston Health Department, Sept., 1919. 
Nederlandsch Tijdschrift, reviewed in the Journal of the American Medical As- 
sociation, Dec., 1919. 
Newcomer, H. S. et al., One Aspect of Syphilis as a Community Problem, 

American Journal of Medical Sciences, vol. 158, no. 141, Aug., 1919. 
Oliver, E. A., Syphilis, an Inestimable Factor in Industrial Inefficiency, Journal 

of Industrial Hygiene, vol. 1, no. 5, Sept., 1919. 
Patterson, J., An Economic View of Venereal Infections, Journal of the 

American Medical Association, vol. 62, no. 9, Feb. 28, 1914. 
Pierce, C. C. and H. F. White, Lesson Taught by Measures for the Control of 

Venereal Diseases, Journal of the American Medical Association, vol. 75, 

no. 17, Oct., 1920. 
Pollock, Horatio, The Economic Loss to the State of New York on Account of 

Syphilitic Mental Diseases during the Fiscal Year Ending June 30, 1917, 

Mental Hygiene, vol. ii, no. 2, April, 1918. 
Porter, H. W., A Statistical Study of Extragenital Chancres, Archives of 

Dermatology and Syphilology, vol. 38, no. 1. 
Programme of Medical Education and Law Enforcement Measures, Issued by 

the Treasury Department, U. S. Public Health Service, chapter xvi, " Public 

Effort vs. Syphilis.' > 
Pusey, W. A., Syphilis as a Modern Problem, Chicago, American Medical As- 
sociation, 1915. 
Report of the Massachusetts General Hospital, 1918-19. 
Report of the Royal Commission on Venereal Diseases, Final Report of the 

Commissioners, London, 1916. 



THE COMMUNITY 233 

Rhys, O., Analysis of 1500 Cases of Venereal Diseases, All Male, at the King 

Edward VII Hospital Clinic at Cardiff, Wales, Sooial Hygiene Bulletin, 

vol. vii, no. 1, Jan., 1921. 
Shillitoe, A., The Primary Lesions and Early Secondary Symptoms, as Seen in 

the Female, A System of Syphilis, London, Frowde, Hodder, and Stoughton, 

1914, second edition, vol. 1. 
Sooial Hygiene Bulletin, vol. vii, no. 2, Feb., 1920. 
Stokes, J. H, To-day's World Problem in Disease Prevention. Issued by the 

U. S. Public Health Service, Treasury Department, Washington, D. C, 1919. 

, The Third Great Plague, Philadelphia and London, W. A. Saunders Co., 

1917. 

and H. E. Brehmer, Syphilis in Railroad Employees, Journal of Industrial 

Hygiene, vol. 1, no. 9, Jan., 1920. 
Thibierge, A., Syphilis and the Army, London, University of London Press, Ltd., 

1918. 
Vedder, E. B., Syphilis and Public Health, Philadelphia and New York, Lea 

and Febiger, 1918. 
Williams, F. E., Relation of Alcohol and Syphilis to Mental Hygiene, AmericaAX 

Journal of Public Health, vol. 6, 1916. 



INDEX 



Abortions as result of syphilis. 48 
Accidents 

caused bv inefficiency of syphilitica, 

219 
to pregnancies 

in families of svphilitics, 121, 

127 
in nonsyphilitic families, 121, 
134 
Adoption of congenital syphilitica, 

92, 226 
Arsphenamin 

for free distribution, 154 
use of in congenital syphilis, 106 
value of in early syphilis for 
sterilization, 5 
Attenuation of virus, 45 
Attitude toward syphilis, 223 
mistaken, 223 
of different individuals, 225 

Birth-rate in families of syphilitica, 

120, 127 
Births, ratio of still to live in families 

of syphilitics, 123 
Blindness and syphilis, 64, 212 
Bones, involvement of, in congenital 

syphilis, 66 
Broken home as result of syphilis, 165 

Cerebrospinal syphilis 

and syphilis in the family, 123 
in congenital syphilitics, 73 
Chancre 

extragenital, 188 
location of, 197 
Character defects and congenital 

syphilis, 76, 78 
Childbearing, effect of svphilis on, 37, 

47 
Childlessness in families of syphi- 
litics, 117, 125, 133 
Colles' law, 41 
Compensation in relation to svphilis, 

223 
Congenital syphilis 
and adoption, 92, 226 
and central nervous system involve- 
ment, 70 
cerebrospinal syphilis, 73 
juvenile paresis, 72 
juvenile tabes, 74 
and constitutional inferiority, 81 
and delinquencies, 78 
and epilepsy, 74 



[234] 



Congenital syphilis — Continued 
and feeble-mindedness, 66 
and marriage, 81 
and placing of infants, 226 
and precocity, 70 
and various psychopathies^ 75 
care of, 160 

conditions accounting for, 43 
confusion with acquired, 86 
date of recognition, 36 
diagnosis of, 51, 59, 82, 88 

importance of early, 103 
hospital schools for, 107 
incidence of in general child popu- 
lation, 50 
incidence of in syphilitic families, 

55 
late, 62 

latent periods in, 42, 61, 104 
prognosis, 102, 104, 106 
severity of, not related to severity 

of parental syphilis, 45 
social difficulties, 91 
stigmata of, 62, 83 
symptoms of, 57, 83 
treatment 

importance of early, 94 

of parents of congenital syphi- 
litics, 94, 96 

prevention of symptoms by, 104 

to minimize social handicaps, 108 

type of treatment in, 105 

value of, 104 
usage of term, 36 
Wassermann reaction as symptom 
of, 104 
Conjugal syphilis, 19, 23 
causes of, 25, 29 
contagiousness in, 24, 25, 26 
education to prevent, 29 
effect of war on, 24 
importance of problem, 34 
incidence of in male and female, 19, 

32 
infection not suspected in, 33 
latent, 31 

methods of prevention of, 33 
symptoms in husband and wife, 30 
time of marriage in relation to in- 
fection, 27 
when original patient infected, 24 
Contagious cases, reporting of, 102 
Contagiousness 

all syphilitics not contagious, 225 
and homeless individuals, 199 
and marriage, 168 



IXDEX 



235 



Contagiousness — Con tinu ed 

and occupation, 204 

and travel, 199 

by extragenital methods, 187, 199 

cleanliness as protection against, 
197 

during primary period, 4 

during secondary period, 8 

effect of time on, 24, 26 

legal methods to prevent, 228 

of body fluids, 197 

of congenital syphilitics, 81, 91, 22(5 

of late stages, 205 

of paretics, 205 

treatment as protection against, 5, 
25, 198 

type of lesion in relation to, 25 
Constitutional inferiority and congeni- 
tal svphilis, 81 
"Cure" 

compared with sterilization, 9 

confusion with latency, 11 

possible with adequate, early treat- 
ment, 6 

Deafness 

and syphilis, 212, 213 
as a handicap, 93 
in congenital syphilis, 65 
Delinquencies and congenital svphilis, 

78 
Diagnosis 

importance of, 13 

of congenital svphilis, 51, 59. 82, 
88, 103 
and acquired syphilis, 86 
by Wassermann reaction, 84 
often late, 88 
of interstitial keratitis, 63 
of primary period 

by demonstration of organism, 3 
by history, 2 
by inspection, 2 
by Wassermann reaction, 3 
of secondary period 
by clinical picture, 8 
by laboratory findings, 8 
of tertiary period 
by clinical signs, 12 
by spinal fluid examinations, 13 
by Wassermann test, 13 
Divorce 

as a result of syphilis, 219 
from a syphilitic, 178 
Doctor 

and examination of families of pri- 
vate patients, 149 
and follow-up of private patient, 

156 
and marriage of a svphilitic, 174, 

181 
and social worker, 146 
Education to prevent conjugal svphi- 
lis. 29 



Effects of syphilis on different mem- 
bers of family, 136 
Emotional disorders and congenital 

syphilis, 76 
Epidemics 

of extragenital syphilis, 190 
from kissing, 197 
Epilepsy and congenital syphilis, 74 
Examination 

of mates of syphilitics, 30, 34 
of spinal fluid, 85 

phvsical, of child and familv, 83, 88, 
90 
Extragenital 
chancre, 187 

chancre from kissing, 189, 197 
chancre from perversions, 189 
infection, 187, 199 
and occupation, 204 
eradication by legal means, 228 
escape from, 201 
incidence of, 188 
methods of transmission of, 191 
Extramarital infection before and 
after marriage, 23 

Familial examination 
methods of, 141 
objections to, 145 
technique of securing, 145 
Familial involvement 

after entrance of syphilis, 134 
as shown bv cases, 129 
mild, 132 
none, 134 
severe, 129 
of central nervous system, 136 
Families of syphilitics 

accidents to pregnancies in, 121, 127 
as affected by syphilis, 112, 128, 157 
average number of living children 

in, 120, 127 
before and after entrance of svphi- 
lis, 134 
birth-rate in, 120, 127 
cases showing svphilis in, 129 
childless, 113, 120 
financial difficulties in, 161 
free from syphilitic defect, 113, 117 
incidence of syphilis in, 112, 124 
in which positive Wassermann ap- 
peared, 112, 127 
necessity of examination of, 137 
ratio of stillbirths to live births in, 

123 
technique of securing examination 
of, 145 
Family discord 

and familial examination, 145 
and syphilitic mental disease, 167 
Fear 

as deterrent to promiscuity, 224 
of transmission of syphilis, 158 



236 



SYPHILIS OF THE INNOCENT 



Feeble-mindedness 

and congenital syphilis, 66 

as a social handicap, 93 

incidence of in syphilitic families, 
68 
Fetal deaths and syphilis, 96 
Financial difficulties 

and broken home, 165 

caused by syphilis, 161 
Financial results of syphilis, 205 

indirect, 214 

late, 209 

loss of earning power, 216 

maintenance of institutions, 212 

through actions of paretics, 217 

through destitution of syphilities, 
213 

to Massachusetts, 210 

to New York, 210 

to private charity organizations, 212 
Follow-up 

difficulties and solutions, 152 

of contagious cases, 199 

of families of syphilities, 146 

of treatment cases, 150 

General paresis 

• age of patients when hospitalized, 
166 
and syphilis in the family, 124 
as cause of financial difficulties, 163 
as cause of social difficulties, 167 
comparative frequency in males and 

females, 15 
juvenile, 72 
General weakness and congenital syph- 
ilis, 76 

Healthy offspring 

of syphilitic parents, 102 

of syphilitic women, 43, 56, 81 
History 

diagnostic value in primary period, 
4 

family, as aid to diagnosis of con- 
genital syphilis, 82 

importance in discovery of familial 
syphilis, 141 

medical, of child as aid to diagnosis 
of congenital syphilis, 83 
Home life 

as affected by syphilis, 157, 165 

effect of financial difficulties on, 161 

nursing care as a disturbance in, 161 
Hospitalization 

due to syphilis, 214 

financial results of, 214 

of contagious patients, 101 

of general paretics, 166 

value of, 5, 216 
Hospital schools for congenital syphi- 
lities, 107 
Hysteria and congenital syphilis, 77 



Ignorance of infection, 138 
Immorality in women as cause of in- 
fection, 22 
Immunity 

apparent, of healthy offspring, 42 
apparent, of mothers of syphilitic 
children, 41 
Incapacitation of wage earner 
permanent, 162 
temporary, 161 
Incidence 

of accidents to pregnancies in fami- 
lies of syphilities, 119, 126 
of accidents to pregnancies in non- 
syphilitic families, 121 
of blindness due to syphilis, 212 
of congenital syphilis 
among feeble-minded, 67 
in general child population, 50 
in hospitals and clinics, 50 
in syphilitic families, 55 
of conjugal syphilis, 11, 32 
of deafness due to syphilis, 212 
of extragenital syphilis, 188 
of feeble-mindedness in syphilitic 

families', 68 
of living non-syphilitic children in 

syphilitic families, 56 
of social difficulties in patients with 

syphilitic mental disease, 167 
of sterility in families of syphilities, 

117, 125, 132 
of stillbirths in families of syphi- 
lities, 121 
of syphilis, 205 

among men and women, 14 

effect of war, 218 

in families of svphilitics, 112, 123, 

126 
in married and unmarried women, 

20 
in pregnant women, 97 
in women, 96 
reason for greater frequency in 

men, 19 

shown by frequency of paresis, 14 

shown by Wassermann surveys, 15 

variation in figures according to 

groups studied, 206 

of undiscovered svphilis in infants, 

88 
of unsuspected syphilis, 140 
Incubation period, description of, 2 
Industrial compensation and syphilis, 
221 
decline caused by syphilis, 162 
Industry and syphilis,' 221 
Infant mortalitv as a result of svphi- 
lis, 48, 60 
Infection, syphilitic 
cleanliness as protection against, 

197 
escape of, 201 



INDEX 



237 



Infection, syphilitic — Contimied 
extragenital, 187, 199 
control of, 195 
epidemics, 190 
homeless individuals and, 199 
ignorance of, 138 
innocent, 14 

innocent of married women, 22 
in relation to occupation, 204 
legal methods to prevent, 228 
not suspected in conjugal syphilis, 

33 
travel and, 199 

treatment as protection against, 198 
Innocent infection of married women, 

14, 22 
Interstitial keratitis, cause of inca- 
pacity, 63, 92 
Involvement of 
bones, 66 

central nervous system, 7, 11, 70, 90 
mental processes, 66 
sensory organs, 63 
ear, 65 
eye, 63 
Juvenile tabes, 74 

Kassowitz's law, 45 
Kissing and extragenital chancres, 
189, 197 

as method of spread of syphilis, 9 

epidemic from, 198 

Latent syphilis, 11, 39 

as disclosed by familial examina- 
tion, 138 

in children, 42, 61, 104 
Laws 

concerning physician and marriage i 
of syphilitics, 182 

concerning reporting of contagious 
cases, 152 

concerning syphilis and marriage, 
174 

to prevent contagion, 228 
Legal status of syphilitic women, 21 
Life insurance of syphilitics, 165 
Lues hereditaria tarda, 62 

and deafness, 65 

and f eeble-mindedness, 66 

and interstitial keratitis, 63 

and involvement of bones, 66 

and other eye involvements, 64 

Marriage 

and treatment, 25. 26 - 
laws relating to, of syphilitics, 174 
rate reduced by syphilis, 218 
role of physician in allowing, 181 
safe for congenital syphilitic, 81 
when justifiable for syphilitics, 24, 
168 

American opinion, 171 

French opinion, 170 

German opinion, 169 



Mate of syphilitic 

importance of examination, 30 

value of examining, 34 
Mates of 

syphilitic men, 22 

syphilitic women, 22 
Medical certificate and marriage, 175 
Mercury in congenital syphilis, 106 
Methods of examination to discover 
familial syphilis, 141 

clinical examination and Wasser- 
mann test, 142 

history, 141 

provocative treatment, 145 
Methods of selection of cases for 

study, 55, 126 
Military service, loss to through syphi- 
lis, 215 
Miscarriages as result of syphilis, 48 
Mistakes in interpretation of stigmata 

and symptoms, 228 
Moralistic view toward syphilis, 223 
Morality, double standard of, 19 
Morbidity and syphilis, 157 
Mortality 

of syphilitic infants, 48 

of syphilitics, 165 
Mother, effect of syphilis on mental life 

of, 160 
Mothers of syphilitic children, 38 

apparent immunity of, 41 

Xervous system 

familial type of involvement of, 136 

involvement as bar to marriage, 171 

involvement in congenital syphilis, 
70, 85, 90 

involvement in secondary stage of 
disease, 7 

involvement in tertiary stage of 
disease, 11 
Xeurosyphilitics 

difficulties of following for treat- 
ment, 155 

inefficiency due to, causing loss of 
life, 219 

Oath of Hippocrates, 149, 181 
Occupation 

of paretics, 221 

relation to infection, 204 



Parental syphilis 

relation to juvenile psychopathies, 

75 
results of 

infant or early deaths, 48 
sterility and accidents to preg- 
nancies, 47 
severity of, no relation to severity 

in children, 45 
treatment of, 94 



238 



INDEX 



Paresis 

actions of paretics 
effect on community, 217 
leading to accidents, 219 
cost to California, 210 
cost to community, 209 
cost to England, 210 
cost to Massachusetts, 209 
cost to New York, 210 
juvenile, 71 
Perversions and extragenital chancres, 

189 
Placing out of congenital svphilitics, 

226 
Prevention of syphilis 
legal measures, 228 
methods, 229 
Primary period of syphilis 
apparent innocuousness of, 4 
characteristics of, 2 
contagiousness of, 4 
diagnosis of, 2 
local treatment in, 4 
Productivity reduced by syphilis, 214 
Professional confidence, 229 
Prof eta's law, 42 
Prognosis 

good with early treatment, 6, 9, 60, 

103 
of cerebrospinal syphilis in con- 
genital svphilitics, 73 
of congenital syphilis, 102, 104 
of interstitial keratitis, 63 
of juvenile paresis, 71 
of optic atrophy, 65 
of syphilitic deafness, 66 
of syphilitic infants, 60 
Propaganda in relation to individual, 

224 
Psychoneuroses and congenital syphi- 
lis, 76, 77 
Psychopathies, relation of juvenile to 

parental syphilis, 75 
Psychoses and congenital syphilis, 76, 
78 



Eailroad employees, effect of syphilis 
on, 220 

Secondary period 
and marriage, 171 
characteristics of, 6 
contagiousness of, 8 
diagnosis of, 8 
Sexual intercourse as method of spread 

of disease, 2 
Social difficulties due to congenital 
syphilis, 91 
of patients with syphilitic mental 
disease, 167 
Social worker 
and doctor, 145 
and follow-up of families, 146 



Social worker — Continued 

and follow-up of treatment cases, 
150 

and free treatment, 154 
Sources of infection 

contact between persons, 1, 14 

contact through mediation of ob- 
ject, 1, 9 

extramarital, 23 

kissing, 9 

mother to child, 43 

of married women, 21, 23 

question of paternal, 38 

sexual intercourse, 2 
Spinal fluid 

and marriage, 171 

examination of for central nervous 
system disease, 13 

examination of in congenital syphi- 
lis, 85 
Sterility as a result of syphilis, 47 

in families of syphilitics, 117, 125, 
132 
Stillbirths 

as a result of syphilis, 48 

ratio to live births, 121 
Stigmata of congenital syphilis, 62 
Symptoms 

absence of in some syphilitic 
mothers, 40 

different in parents and children, 45 

of cerebrospinal syphilis in congeni- 
tal syphilitics, 73 

of congenital syphilis, 57, 62 

of interstitial keratitis, 63 

of juvenile paresis, 71 

of primary period, 2 

of secondary period, 7 

of tertiary period, 11 
Syphilis 

acquired, 86 

acquired by women in marriage, 23 

and accidents to pregnancies, 119, 126 

and blindness, 213 

and deafness, 213 

and destitute families, 213 

and divorce, 219 

and fetal deaths, 96 

and financial difficulties, 161 

and home life, 157, 165 

and industrial decline, 162 

and industry, 221 

and marriage, 168 

and mental life of mother, 160 

and war, 215, 218 

as cause of certain types of feeble- 
mindedness, 69 

as cause of lessened earning power, 
214 

as cause of reduced marriage rate, 
218 

as cause of reduced productivity, 
214 



IXDEX 



239 



Syphilis — Continued 

as family disease, 112, 124, 129 

congenital, 36 

conjugal, 19 

date of entry in family, 134 

effect on birth-rate, li4, 118 

effect on different members of 

family, 136 
effect on next generation, 218 
extragenital, 114, 118, 199 

cleanliness as protection against, 

197, 198 
control of, 195 
epidemics of, 190 
escape from, 201 
incidence of, 188 
methods of transmission of, 193 
financial results of, 205 
general description of, 1 
incidence of, 205, 206 
incidence of. in families of syphi- 
litica 112, 124 
incidence of, in married and unmar- 
ried women, 20 
incidence of, in pregnant women, 97 
incidence of, in women, 20, 96 
incubation period, 1 
mistaken attitude about, 223 
primary period of, 2 
secondary period of, 6 
source of, in married women, 21 
tertiary period of, 10, 12 
transmission of, to third generation, 
80 
Standard of living lowered by syphi- 
lis, 219 

Tabes, 74 
Tertiary period 

characteristics of, 10 
clinical diagnosis of, 12 
Transmission 
paternal, 38 
to children, 43, 94 
to third generation, 80 
Treatment 

amount necessary to sterilize in pri- 
mary period, 5 
amount necessary to sterilize in sec- 
ondary period, 9 
and marriage, 25, 26, 169 
and Wassermann reaction, 106 
as protection against contagion, 198 
as result of examination of rela- 
tives, 90 
difficulties of follow-up for, 152 
during pregnancy, 95, 97 
expense of, 154 
in congenital syphilis 
importance of early, 94 
indications for, 102 
of parents of, 94 



Treatment — Continued 

of syphilitic infants, 60, 103, 106 
to minimize social handicaps, 108 
to prevent symptoms, 104 
type of treatment, 106 
value of treatment, 104 
insufficient to protect mate, 19, 25 
of apparently non- syphilitic mothers 

of syphilitic children, 39 
of symptom free children of syphi- 
litic parents, 42, 101 
of syphilitic deafness, 65 
prior to pregnancy, 95 
provocative, 145 

to minimize contagiousness in pri- 
mary period, 5 
to sterilize for ordinary contact in 

secondary period, 9 
value of early in relation to cure, 6 
value of local in primary period, 4 
Treponema 

effect of antiseptics on, 196 
effect of moisture on, 196 
effect of temperature on, 196 
methods of spread, 195 
viability of, 194, 196 
Twins, one may be healthy, 47 

Wassermann reaction 
after labor, 97 
and marriage, 169, 174 
and treatment of congenital syphi- 
lis, 106 
as aid in discovery of syphilis, 142 
as criterion of syphilis, 32 
as routine in institutions, 33 
diagnostic value in primary period, 

3 
diagnostic value in tertiary period, 

13 
interpretation in congenital syphilis, 

84, 103 
limitations of, 142 
negative in infants, 60, 84 
negative in tabes, 142 
positive as indication for treatment, 

101 
positive in secondary period, 8 
syphilitic families in which positive, 

112, 127 
value in survey, 50 
value of treatment before reaction 
positive, 6 
Wassermann survey of mates of syphi- 

litics, 32 
Wet nurses 

directories, 195, 198 
protection of, 198 
Wife, effect of syphilis on mental life 

of, 160 
Work, efficiency reduced by syphilis, 
214 



"HENCE MOM. 

CjOCKT casf 



